Missed or delayed diagnosis

• Genuine concern and communication are important when there has been a diagnostic error, particularly if there is an adverse outcome.
• Follow the open disclosure process and keep the patient well informed.
• Reflect on your practice and what changes you could make to minimise the risk of a diagnostic error happening again.

Diagnostic errors include missed diagnosis, misdiagnosis or delayed diagnosis. When such an error is identified, it is important to act promptly and have a structured process in place to manage the situation, whether you contributed to the error or not. Ensuring a timely and effective response is crucial for patient wellbeing and professional integrity.

Organise a meeting with the patient asap

Depending on the urgency of the diagnosis, contact the patient to inform them of the unexpected finding and its implications as soon as possible. A personal telephone call to set up a face-to-face conversation is better than delegating to another member of the practice. Ensure you document the contact with the patient in the medical record.

Promptly seek advice

Before you meet with the patient, consider contacting a relevant specialist for advice on the likely treatment now required and the impact of the delayed diagnosis. It’s good to be prepared to answer questions and provide a plan when you meet with the patient.

Explain the situation in person

Have a face-to-face, in person discussion with your patient about the new findings. When doing this follow an open disclosure process and acknowledge what has occurred. Be empathetic. You can express regret and say how sorry you are about the unexpected news. An apology should not apportion blame or liability, but rather express empathy to the patient about the events which that have occurred. Refer to our open disclosure factsheet.

Arrange immediate treatment and ongoing management

During your discussion with the patient, explain their treatment options including any additional tests and/or specialist treatment that may be required. We recommend that you  facilitate recommended treatment for the patient, rather than simply providing the patient with a referral letter and advising them to arrange their own follow-up investigations.

After follow up treatment has been arranged, regularly enquire with the patient about their progress.  If supportive treatment is recommended to assist the patient to accept the revised diagnosis, these arrangements should be facilitated.

Consider the cause of the diagnostic error and review practice systems

After making a diagnostic error, some practitioners become overly cautious. Instead, reflect on the situation that resulted in the diagnostic error and critically review any decisions you made. Consider developing criteria for the management of similar presentations in future patients.

It can be helpful to discuss similar scenarios and develop responsive management plans with a trusted peer to learn from the error.

If the diagnostic error was caused or contributed to by a system error, such as follow-up failure or misfiling of pathology or diagnostic imaging reports, review and amend your systems to prevent a recurrence. Learn more in our follow-up and recall factsheet.

Communicate any changes to the patient

Patients like to know that someone has taken ownership of the problem and addressed any issues. You should do this without any admissions regarding liability, and focus on explaining to the patient what changes have been made to avoid a similar situation in the future

Notify us about the incident

As soon as possible after you become aware of the diagnostic error, let Avant know. If you receive a letter of complaint from the patient or their representative, obtain advice from Avant before you respond.

Consider cancelling or refunding your fee

Check your processes to ensure that invoices or fee reminders for the relevant service are not sent at an inappropriate time, as this may unintentionally inflame the situation. Depending on the circumstances, you may choose to forgo or refund a fee. Taking this approach can sometimes help defuse the situation and prevent further escalation.

If you decide to refund or forgo a fee, this is done without admitting liability, or fault, and as a gesture of goodwill. It is important to make this clear in your verbal and written communication with the patient to clarify the intent behind your decision.

In some cases, it might be best to ensure the patient does not incur out-of-pocket expenses for any subsequent discussions you have with them regarding the issue. If you are uncertain, seek advice from Avant.

If you start treating a patient who has experienced a diagnostic error involving another practitioner, the situation needs to be managed carefully. Diagnostic errors are not necessarily avoidable or the direct result of a mistake.  The situation is almost always clearer with hindsight.

When discussing a diagnostic error and its implications, stick to the facts. You only have the patient’s understanding of the history and as such, it is better to avoid any implied or stated criticism of the doctor(s) involved in the error. It is not uncommon for a legal claim or complaint to be pursued by a patient after throwaway comments by a second doctor, which were not intended to be a criticism.

Remain professional and objective during discussions with the patient.

If the patient’s solicitor seeks a report for a compensation claim, ensure any reports are factual and objective. As the patient’s current treating doctor, your role is to provide a factual account of your care, not to offer a medico-legal opinion on the treatment provided by other doctors. Providing an opinion could create challenges in your ongoing treatment relationship with the patient.  If you are unsure about how best to proceed, contact Avant for advice.  

Providing and receiving feedback can help prevent diagnostic errors. If you or a colleague are involved in a diagnostic error, it’s important to give and accept feedback constructively. Peer support can be invaluable after an error has been made. 

When providing feedback, think about what you would expect from your colleague if the roles were reversed. No one is infallible. Inform your colleague of the correct diagnosis and allow time for them to process the feedback and ask questions.

When receiving feedback, view the experience as an opportunity to improve your practice. Be open, not defensive, ask questions and reflect on your actions and decisions.

A collaborative approach will help correct the error, modify any systems, and foster a supportive environment for continuous learning and improvement in patient care.

Reflecting on what may have contributed to a diagnostic error can assist in reducing the chance of a similar situation in the future. 

Our five tips to help reduce the risk of diagnostic error are:

• develop a list of differential diagnoses
• take a diagnostic time out – pause to reflect
• be comfortable saying “I don’t know”
• use checklists and mnemonics to provide prompts
• seek a second opinion.

A comprehensive list of error mitigations can be found in our e-Learning course “Reducing diagnostic errors”. 

Avant claims insights – Diagnosis-related claims

Avant factsheet: Open disclosure: how to say sorry

Avant factsheet: Follow-up and recall

Website: Society to Improve Diagnosis in Medicine  

For medico-legal advice, please contact us here, or call 1800 128 268, 24/7 in emergencies.