How to reduce the costly risks of office-based diagnostic errors

The medical community has long assured patients that routine screenings for cancers like prostate, lung, breast, and colorectal can save lives through early detection. However, malpractice claims data reveal a troubling paradox: These cancer diagnoses are among those that patients most frequently claim are missed in office-based health care.

The challenge of diagnostic error in office-based practices is real. Research into five years of Coverys’ closed medical malpractice claims—6,009 events closed from 2020 to 2024—found that the largest percentage of diagnosis-related claims/events (34%) occurred in office-based settings. Nearly half (45%) of those office-based diagnostic allegations involved a missed or delayed cancer diagnosis.

Diagnosis-related claims involving office-based care also accounted for the largest percentage of indemnity payments for all care settings. More than half of these claims (53%) were closed with an indemnity payment. Furthermore, the average indemnity was $661,000—more than twice the $323,000 average for non-diagnostic claims.

Health care risk managers are mindful of a profound truth: We have not yet fully invested in developing an ambulatory culture of safety as we have in inpatient settings, even though some office-based settings have begun to embrace the concept. But that’s actually good news. It means we have both an opportunity and a “playbook” for making that investment and, consequently, changing the trajectory of office-based diagnostic error.

Raise awareness

The first step toward stronger ambulatory diagnostic processes is to raise awareness of their impact, as well as the practical challenges physicians face. The reality is that the consequences of diagnostic error in office-based settings can be devastating—taking a personal, clinical, and financial toll on both families and physicians.

The statistics alone are sobering: Patients died in about one-third of the events analyzed in the claims research. Another 22% suffered a high-severity injury. Together, these distressing events accounted for 72% of the indemnity paid. It’s also worth noting that indemnity payments are skyrocketing, as better-informed juries increasingly are awarding what are often called nuclear (and, more recently, “thermonuclear”) verdicts. One practice, for instance, recently experienced a $10 million verdict for a missed diagnosis.

Nearly every physician must now contend with rising malpractice insurance premiums as a result of higher verdict awards. However, for those physicians directly involved in an alleged diagnostic error, there may be additional personal burdens and “soft costs.” Such situations can have a profound influence on a physician’s relationship with their patients, their personal life, and professional reputation and can even lead to feelings of burnout as they try to balance the multitude of challenges involved.

After all, even as physicians try their best, the surrounding systems and safety culture can sometimes fall short of supporting that effort.

Office-based practices typically face difficult production pressures, long clinical timelines (i.e., conditions that evolve slowly), and patient engagement obstacles. Many office-based physicians may lack the time and resources necessary to gather, track, and discuss diagnostic error data and anecdotes.Furthermore, many practices may not have the structured processes needed not only to identify but also to embrace their vulnerabilities, so they can learn from them. Seldom are they required to conduct periodic quality and safety reviews or root-cause analyses, as in inpatient settings.

In other words, a safe, structured approach for acknowledging and discussing errors is missing from most office-based settings.

Invest in a culture of safety

To address the clinical and financial impacts of missed diagnoses, office-based practices must tackle this industrywide deficiency by investing in a culture of safety. Fortunately, inpatient settings offer a playbook based on their experiences. That playbook starts with investing in policies and procedures designed to close the loop with patients and to ensure the adoption of best practices based on learnings.

Here are six key “investments” likely to pay diagnosis dividends for office-based practices:

1. Leverage current risk management services that may be available. Risk managers can help physicians understand the need for processes to capture and talk about diagnostic error appropriately in the context of risk. Practices that do not have such services can consider seeking access to risk managers through their affiliated hospitals or health systems, their medical professional liability insurance company, professional associations, or other available resources.
2. Consider training practice managers to gather data on missed or nearly missed diagnoses.Take advantage of educational risk management programs designed for non-clinical practice managers. A short, risk-focused class could help practices use existing resources to gather powerful insights over time.
3. Leverage evidence-based tools such as the Agency for Healthcare Research and Quality (AHRQ) TeamSTEPPS framework for diagnostic safety. Such frameworks can help office-based settings solidify diagnosis-related roles and responsibilities within the care team.
4. Conduct periodic case review. Give physicians a set amount of time each month or quarter to review their cases or conduct a root cause analysis on missed or nearly missed diagnoses. In tandem, create a forum for physicians to discuss their unique perspectives on diagnosis challenges and solutions. At the practice level, assess each physician's areas of opportunity.
   For example, are patient histories being updated at each visit? Does the practice have processes in place to ensure patient histories are reconciled, much like medication reconciliation? Interestingly, the claims research identified the history and physical evaluation as the single biggest vulnerability in the process of care, contributing to 49% of events and 41% of indemnity paid. Therefore, practices should have a way to ensure that updates to a patient’s history information are appropriately acted upon.
5. Consider hiring (or leveraging the time of) a clinical nurse—even if only part-time—to gather data and create an office registry on missed or nearly missed diagnoses, integrating case review withdocumented patient complaints. Or track and review populations most vulnerable to these misses and delays, e.g., all patients with a chief complaint of breast lumps, or all patients who call saying, “I’m not feeling any better since my last visit,” for example.
6. Adapt policies and protocols similar to those used in the emergency department and inpatient settings aimed at reducing patient rebound. These might include strategies for improving post-visit follow-up communication with patients, for instance.

Use small investments to drive big impacts

It’s clear from research data that office-based diagnostic errors persist and pose significant clinical and financial consequences. Breakdowns in common, everyday processes and communications could turn potentially preventable conditions into catastrophic outcomes. Therefore, we must create a culture of safety in ambulatory practices just as we have in inpatient settings.

Just as inpatient physicians do, office-based physicians need a safe space to analyze and discuss vulnerabilities in the diagnostic process. They need systems, protocols, and procedures that enable them to acknowledge and learn from their diagnostic vulnerabilities. As an industry, we must recognize that making small investments in a culture of safety now can pay big dividends over the long run for practices and patients alike.

Dana Siegal, RN, CPHRM, CPPS, is Vice President of Risk Management and Analytics at Coverys, an innovative provider of medical malpractice insurance dedicated to helping policyholders anticipate, identify, and manage risks to reduce errors and improve outcomes. During her extensive career, Siegal, a registered nurse, has served as Director of Patient Safety at CRICO Candello and on the Board of Directors for the Society to Improve Diagnostic Medicine (which has since transitioned into the Community Improving Diagnosis in Medicine).