THE 5 MOST MISDIAGNOSED CONDITIONS Cancer-Related Issues: Early and accurate diagnosis of cancer is important to optimize patient outcomes in terms of local disease control, overall survival, and health-related quality of life. 1 Cancers detected before they metastasize are easier to treat and associated with better outcomes and survival rates. For example, lung cancer diagnosed at the localized stage has a relative 5-year survival rate of 57% compared with 7% when found at the distant or metastatic stage. 2 A recent review found that the highest cancer misdiagnosis rate was for lung cancer at 22.5%, while the lowest misdiagnosis rate was for prostate cancer at 2.4%. 3 Misdiagnosis of lung cancer can result from failure of the provider to recognize symptoms, such as shortness of breath and coughing up blood, that often overlap with other common conditions, including pneumonia, asthma, chronic obstructive pulmonary disease, acid reflux, and tuberculosis. 4 Additionally, approximately 90% of missed lung cancer cases occur on chest X-ray . Although CT is much more sensitive than chest radiography, lung cancer can still be missed. In these cases, observer error, lesion characteristics, and technical defects are the main causes of missed lung cancer. 5
Misdiagnosis Rates for Cancer 3
Lung
2.5%
Melanoma Colorectal
13.6%
9.6% 8.9% 2.4% 1.1%
Breast
Prostate
Total Cancers
Neurologic-Related Issues: Misdiagnosis in patients with neurologic symptoms associated with conditions such as multiple sclerosis (MS), epilepsy, Bell’s palsy, dementia, and migraine, may result in ineffective and potentially toxic treatment. Misdiagnosis of MS may expose patients to the adverse effects of disease-modifying agents with no chance of benefit while misdiagnosis of epilepsy may expose patients to the risks of antiepileptic drugs and potential loss of a driving license or job. In addition, as occurs with misdiagnosis in other conditions, misdiagnosis fails to address symptoms, delays appropriate therapy, and may result in a worse prognosis. 6 MS is often misdiagnosed because it remains a clinical diagnosis that relies on appropriate interpretation of radiologic data in patients with an appropriate history and neurologic examination. In a study 7 of patients misdiagnosed with MS, alternate diagnoses included migraine alone or in combination with other diagnoses 22%, fibromyalgia 15%, nonspecific or nonlocalizing neurologic symptoms with abnormal MRI 12%, conversion or psychogenic disorders 11%, and neuromyelitis optica spectrum disorder 6%. Duration of misdiagnosis was 10 years or longer in 33% of patients and an earlier opportunity to make a correct diagnosis was identified for 72%. In addition, 70% of patients received disease-modifying therapy and 31% experienced unnecessary morbidity because of the misdiagnosis. 7 Cardiac-Related Issues: Despite significant advances in the diagnosis and treatment of cardiac conditions, misdiagnosis remains a concern. Although heart disease is often considered a man’s disease, almost as many women as men die of heart disease each year in the US. 8 Heart disease is the leading cause of death in women, responsible for 1 in every 4 deaths. But almost two-thirds of women who die suddenly from heart disease had no previous symptoms. Diagnosis of an impending heart attack in a woman may be more difficult than in men, because women often show different early signs and symptoms. 9 A study of closed medical malpractice claims involving undiagnosed heart disease in women from 2011 to 2015, found that in 70% of claims the patient died when her heart condition was not correctly diagnosed and 28% had heart muscle damage from myocardial infarction. 9 The diagnosis of heart failure can be easily missed due to similar symptoms with other conditions especially respiratory diseases. A recent review found that the rate of misdiagnosis of heart failure ranged from 16.1% in the hospital setting to 68.5% when a general practitioner referred patients to a specialist setting. The most common cause for misdiagnosis in this study was chronic obstructive pulmonary disease. 10 Surgical Complications: Wrong side surgery/wrong patient surgeries are considered sentinel events by the NQF to describe a significant adverse medical error that should never take place. In Pennsylvania, during the period of 2015-2019, there was an average of 1.42 wrong-site surgeries reported each week or 368 wrong side surgery events during a period of 260 weeks. 11 Four of the most common errors in spinal surgery include operating on the wrong patient, doing the wrong procedure performing wrong level surgery, and/or performing wrong side surgery. 12 A retained surgical sharp (RSS) is a never event and defined as a lost sharp (needle, blade, instrument, guide wire, metal fragment) that is not recovered prior to the patient leaving the operating room. A “near-miss” sharp (NMS) is an intraoperative event where there is a lost surgical sharp that is recovered prior to the patient leaving the operating room. A recent, large-scale national survey-based study estimated the incidence of these events. 13 Most of each respondent group reported 1–5 lost sharp events over the last year: 91.7% of surgeons; 75.5% of anesthesiologists; 80.5% of nurses/ technologists. Unlike previous estimates that lost sharp objects are rare events, data from this survey suggest a higher incidence of 2.7 events per 10,000 surgeries or approximately 1 event per every 3800 surgeries. Surgical site infection, which is defined by the CDC as infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure, or within 90 days if prosthetic material is implanted at surgery, is among the most common preventable complication after surgery. Surgical site infections occur in 2% to 4% of all patients undergoing inpatient surgical procedures. Although most infections are treatable with antibiotics, they remain a significant cause of morbidity and mortality after surgery. They are the leading cause of readmissions to the hospital following surgery, and approximately 3% of patients who contract an infection will die as a consequence. Although infections are less common following ambulatory surgery than after inpatient procedures, they are also a frequent source of morbidity. 14 Urologic-Related Issues: Urologic conditions that are misdiagnosed range from urinary tract infection (UTI) and asymptomatic bacteremia, 15, 16 to interstitial cystitis/bladder pain syndrome, 17 to stress urinary incontinence, 18 to spontaneous rupture of the urinary bladder. 19 A study 15 of women who presented to an urban academic emergency department with genitourinary symptoms or diagnosed genitourinary infection found that 57% were treated for a UTI, without performing a urine culture. In addition, 14 of 22 women who were later found to have a sexually transmitted disease were misdiagnosed with a UTI. Although UTIs are common in hospitalized patients, many patients with asymptomatic bacteremia are misdiagnosed with UTI. In one study, approximately 30% of patients received antimicrobials within 48 hours prior to urine culture. 16 Some cases of misdiagnosis have severe consequences as is the case of spontaneous rupture of the urinary bladder, which is a rare and often life-threatening condition. The common misdiagnoses reported in a literature review included acute abdomen, inflammatory digestive disease, bladder tumor or inflammation, and renal failure. 19
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