Reducing Diagnostic Mistakes in the Emergency Department: 10 Practical Strategies from Healthcare Professionals

Diagnostic mistakes in the emergency department (ED) are among the most significant—and often overlooked—dangers in contemporary healthcare. With lives at stake, patients faced with a misdiagnosis may endure major injuries or even die. In a recent episode of the KevinMD podcast, healthcare leaders and former nurses Susan L. Montminy and Marlene Icenhower address this urgent issue and present a solutions-oriented approach to reducing diagnostic errors through a collection of ten specific strategies, detailed in their article, “Addressing an Overlooked Challenge: 10 Recommendations to Minimize Diagnostic Mistake in the Emergency Department.”

Here’s a summary of the main issues and insights discussed during their conversation, as well as practical tools that hospitals and healthcare providers can start using immediately.

The Magnitude of the Issue

Susan Montminy notes that diagnostic errors have only recently been recognized as a significant cause of patient harm. Although the 1999 publication “To Err is Human” ignited the patient safety movement, serious focus on diagnostic errors did not occur until the 2015 Institute of Medicine’s report, “Improving Diagnosis in Health Care.” A striking statistic reveals that around 795,000 Americans die or face permanent disability annually due to misdiagnosis.

Supporting this claim, internal data over five years from Montminy and Icenhower’s malpractice and risk management firms indicated that 26% of claims were related to diagnostic errors, which accounted for 41% of the indemnity paid—showing that these errors are both prevalent and expensive.

Why the ED is Particularly Vulnerable

The emergency department is arguably the most complicated setting for achieving diagnostic precision. Icenhower notes, “The ED is chaotic”—a constantly shifting and interruption-prone environment that heightens the risk of clinical oversights. Clinicians frequently need to make swift decisions about patients they may not know well, often lacking complete medical histories.

Moreover, emergency medicine professionals regularly face:
– High patient volume and staff exhaustion
– Reliance on heuristics and “intuitive” decision-making
– Incomplete or contradictory data
– Time limitations impacting comprehensive evaluation

These elements combine to increase the likelihood of diagnostic errors—especially for urgent or ambiguous conditions like sepsis, fractures, or emerging infections.

Real Situations: Illustrations of Diagnostic Errors

Frequent instances of misdiagnosis in the ED include:
– Confusing gastrointestinal issues for a trivial problem like a UTI, when they actually indicate a surgical abscess.
– Incorrectly labeling seemingly benign symptoms in young patients, such as ascribing rectal bleeding to hemorrhoids without investigating more serious—though less likely—causes like colon cancer.
– Depending on a preliminary X-ray interpretation that overlooks a fracture, without reassessing after receiving the formal reading.

In these cases, intuitive biases and an absence of re-evaluation significantly influence outcomes.

Grasping Cognitive Bias in Medicine

Cognitive biases are mental shortcuts that clinicians utilize under pressure, often rooted in prior experiences or assumption-based probabilities. While convenient, they can lead to diagnostic closure—where a physician prematurely agrees on one option and disregards conflicting information.

Icenhower and Montminy stress the necessity for clinicians to recognize the existence of biases instead of denying them. Identifying and discussing biases as part of the diagnostic process is an essential step towards enhancement.

10 Strategies to Minimize Diagnostic Errors in the ED

Montminy and Icenhower offer ten actionable, evidence-based recommendations to minimize diagnostic errors in high-paced emergency environments. Here are their key takeaways:

1. Utilize “Working Diagnoses”
Encourage physicians to view initial diagnoses as provisional hypotheses—not absolute truths. This nurtures ongoing reassessment and adaptability to new information.

2. Establish Diagnostic Timeouts
Implement structured pauses (akin to surgical timeouts) where providers verify whether the diagnosis remains valid, particularly when treatments are ineffective or results are unclear.

3. Reduce Interruptions
Optimize ED workflows to minimize distractions, known to contribute to errors, especially during history-taking or documentation.

4. Acknowledge and Tackle Cognitive Biases
Clinicians should openly engage with colleagues about potential biases. Awareness enhances decision-making.

5. Embrace a Collaborative Approach
Diagnosis is a collective effort. Include nurses, residents, and consultants in challenging cases. Diverse viewpoints can reveal overlooked factors.

6. Use Triggers for Review
Recognize indicators like repeat visits, unresolved symptoms, or unusual lab findings as prompts for diagnostic re-evaluation.

7. Normalize Diagnostic Uncertainty
Foster an environment where recognizing uncertainty is accepted and promoted, rather than seen as a flaw.

8. Document Diagnostic Errors Like Other Adverse Events
This practice allows teams to assess contributing factors and pinpoint systemic weaknesses—similar to tracking falls or medication mistakes.

9. Utilize Technology Wisely
Enhance EHR systems to ensure critical clinical information is easily accessible. Foster collaboration between IT and frontline practitioners.