Table 1. 24 Analysis Questions from the Joint Commission Framework for Root Cause Analysis and Corrective Actions. 27
1. What was the intended process flow?
13. Did staff performance during the event meet expectations?
14. To what degree was all the necessary information available when needed?
2. Were there any steps in the process that did not occur as intended?
Accurate? Complete? Ambiguous?
3. What human factors were relevant to the outcome?
15. To what degree is communication among participants adequate? 16. Was this the appropriate physical environment for the processes being carried out?
4. How did the equipment performance affect the outcome?
5. What controllable environmental affected the outcome? 6. What uncontrollable external factors influenced the outcome? 7. Were there any other factors that directly influenced this outcome? 8. What are the other areas in the healthcare organization where this could happen? 9. Was staff properly qualified and currently competent for their responsibilities? 10. How did actual staffing compare with ideal level? 11. What is the plan for dealing with staffing contingencies?
17. What systems are in place to identify environmental risks?
18. What emergency and failure-mode responses have been planned and tested?
19. How does the organization’s culture support risk reduction?
20. What are the barriers to communication of potential risk factors?
21. How does leadership address the continuum of patient safety events, including close calls, adverse events, and unsafe, hazardous conditions?
22. How can orientation and in-service training be improved?
23. Was available technology used as intended?
12. Were such contingencies a factor in this event?
24. How might technology be introduced or redesigned to reduce risks in the future?
or by limits on screening recommendations (e.g., colorectal cancer). However, delayed diagnosis can lead to worsening conditions and poorer prognosis. In general, gastrointestinal syndromes/ symptoms may be classified into three general diagnostic categories: organic, motility, or functional disorders. 79,80 Functional GI disorders are idiopathic disorders of gut-brain interaction and, unlike organic and motility disorders, diagnosis involves identification of symptom clusters. As such, misdiagnosis is more common. Another important consideration is GI symptom- specific anxiety, an important perpetuating factor that describes threatening interpretation and out- of-proportion behavioral response to GI sensations. This anxiety to real GI symptoms and the frequency of psychiatric comorbidity can lead to functional GI syndromes being dismissed as psychological or psychosomatic in nature. Cardiology-Related Issues The clinical presentation of chest pain has many possible etiologies, ranging from benign (e.g., panic/anxiety, pneumonia, peptic ulcer, gastroesophageal reflux disease, and pericarditis) to life-threatening (e.g., pulmonary embolism, acute coronary syndrome [ACS], aortic dissection, and pneumothorax). In many cases, it is best to rule out the more urgently threatening possibilities before testing for other causes. Of the potentially life-threatening causes of chest pain, ACS is the most prevalent. Although a large percentage of individuals with suspected ACS will be seen initially in emergency departments, patients in any healthcare setting, regardless of other diagnoses, may abruptly develop chest pain suspicious for ACS. When a patient presents with clinical signs suspicious for myocardial infarction, immediate medical intervention is directed at confirming a diagnosis and stratifying the person’s risk for adverse events such as cardiac arrest and severe/significant damage to the myocardium. 67 It is
important to note that while some patients will present with classic ACS-related chest pain (tightness, sensation of pressure, heaviness, crushing, vise- like, aching pain in the substernal or upper left chest), many patients, particularly women and older patients, will present with “atypical” ACS-related chest pain. 71,72 Words commonly used to describe “atypical” chest pain associated with ACS include numbness, tingling, burning, stabbing, or pricking. Atypical chest pain location includes any area other than substernal or left sided, such as the back, area between shoulder blades, upper abdomen, shoulders, elbows, axillae, and ears. 69,70,71,72 Aside from atypical clinical presentation, other possible causes of missed ACS diagnosis include failure of interpretation of the history, failure to correctly interpret the electrocardiogram, failure to perform an electrocardiogram when necessary, and lack of proper use of cardiac enzyme test. 73 Neurologic-Related Conditions Delayed or missed diagnoses of neurologic conditions may result in serious morbidity and mortality. Headaches are a common presenting condition in acute and primary care, and an estimated 5% of all patients admitted to emergency departments have neurologic symptoms. 61 Acute headache with neurologic symptoms may be misdiagnosed as stroke. 62,83 In addition, missed spinal fracture diagnoses are one of the leading causes of malpractice claims against radiologists 74 . One of the most common neurologic conditions is headache; however, it has been estimated that 50% of migraine patients remain undiagnosed or misdiagnosed, and only a small number (8% to 10%) of individuals with migraine take migraine-specific medications such as triptans or ergotamines. 84,85 Patients suffering from daily migraines may be misdiagnosed with chronic sinusitis or rhinitis and repeatedly and unsuccessfully treated with broad-spectrum antibiotics. 81,82 The diagnosis of migraine is based solely on a constellation of signs
2024 Most Misdiagnosed Conditions As of 2024, the Florida Board of Medicine has determined the five most misdiagnosed conditions to be 56 : • Oncology-related conditions • Gastroenterology-related issues • Cardiology-related issues • Neurologic conditions • Infectious disease-related conditions Oncology-Related Conditions The early detection and diagnosis of cancers is crucial for selecting the appropriate treatment approach and to ensure an optimum outcome. However, an estimated 12% of cancer patients are initially misdiagnosed, and the missed or delayed diagnosis of cancers remains a significant cause of medical malpractice claims. 57,58 The causes of missed diagnoses vary widely among cancers in different parts of the body. In many cases, patients who do not fit the typical profile for a specific cancer (e.g., young age) may be underdiagnosed, and it is important that cancer is considered as part of the differential diagnosis in ambiguous cases. 58,59,5 In order to prevent missed or delayed cancer diagnosis, practitioners may take steps to ensure adherence to clinical guidelines for screening and diagnosis, use tools to facilitate communication, and engage strategies to ensure appropriate follow- up. 75 Gastroenterology-Related Conditions Gasteroenterologic conditions may present with nonspecific complaints (e.g., abdominal pain, nausea) common to a variety of illnesses, complicating and delaying diagnosis. In one study of patients with pancreatic cancer, more than 30% were initially misdiagnosed, most commonly with gall bladder disease. 78 Diagnosis and screening for gastrointestinal disorders may be complicated by a lack of definitive test (e.g., irritable bowel syndrome)
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