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A Thousand Points of Risk


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A Thousand Points of Risk

By Jock Hoffman, CRICO

Related to: Ambulatory, Diagnosis, Cures Act: Opening Notes

A recently published study measuring the scope of care in an ambulatory practice (Harvard Vanguard Medical Associates) notes that a typical (full-time) general practitioner annually manages more than 1,100 different diagnoses, medications, lab tests, referrals, imaging studies and procedures; some do many more than that. That is both a testament to the complexity of primary care and a yardstick for the risk inherent in a profession that combines so many variables.

Malpractice claims and suits alleging a diagnostic error in a (non-ED) outpatient setting account for 67 percent of all CRICO cases based on care rendered since 2002. Roughly half of those involve cancer, but more than 50 different types; an additional 50 non-cancer diagnoses make up the other half. For 75 diagnosis-related cases involving Emergency Department patients from the same time period, more than 30 different final diagnoses were listed. Clearly, patient safety cannot focus too narrowly on particular case types but, rather, needs to address the potential pitfalls in the diagnostic process for all patients, especially outpatients.

There is, however, value in applying to a broader set of circumstances, generalizable lessons drawn from a subset of high-severity claims, particularly those alleging a failure to diagnose breast, colorectal, or prostate cancer.


Self-detected symptoms

Whether or not you can detect what the patient has indicated (e.g., breast lump, bloody stool, abdominal pain) he or she expects to be followed to conclusion. Leaving a self-detected complaint unresolved (in the patient's mind) may foster distrust. A subsequent diagnosis may be considered "missed" by a patient who believes he or she wasn't taken seriously from the beginning.

Patient risk factors

An insufficient or outdated history (personal and family) can inhibit risk-stratified screening—and timely referrals for high-risk counseling. Patients may need to be prompted and guided through the process of providing an informative history.

Test results

Following an ordered diagnostic test through to a conclusion requires both the ordering physician and other clinicians involved in the process to confirm that it was conducted, and that the results were interpreted, communicated to all pertinent parties, and discussed with the patient. Unconfirmed assumptions put both patient and providers at risk.


A follow-up plan has to become a follow-up action. Documentation, especially when shared with the patient and family members, helps, but only if it is structured with alerts to missed appointments or milestones.


A referral treated as a one-way engagement exposes you and your patients to diagnostic delays if anything alters the intended course of events. Make sure to coordinate a closed-loop communication process with clinical colleagues, and clarify for the patient the roles of each of his or her providers.

Managing expectations

Any doubts you have that you will be able to translate a patient's complaint or symptoms or test results into a concrete diagnosis need to be balanced against the patient's expectations. Sharing the limits of the diagnostic process with a patient may help maintain his or her trust during a period of anxiety, and ultimately protect you against an allegation of substandard practice.

Given the vast amount of information patients expect their physicians to learn, retain, and appropriately apply, those physicians who complement their routines and memory with decision support tools are likely to make fewer missteps along the diagnostic path.

Additional Material

Prostate Cancer After No Screening

March 29, 2012
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