Diagnosis involves the collection and analysis of data to arrive at a conclusion, discussions with the patient about that conclusion, and an appropriate treatment plan. There are multiple factors that can complicate the process for patients and providers. It may take years for symptoms to be fully understood. The time and subtleties of (intentional) watchful waiting, patients hoping their symptoms go away, comorbidities, missed appointments, and numerous other factors further expose the process to missteps. While what gets missed in the office setting includes diagnoses of cancers, fractures, and infections, the reasons why those diagnoses are missed are less diverse. Focusing on key vulnerabilities (page 9) and the most frequently missed diagnoses (page 7) can significantly reduce diagnostic error, patient harm, and the likelihood of a malpractice claim. In legal proceedings, early indicators such as a self-detected breast lump, rectal bleeding, or a lingering cough, can point an accusing finger at the clinicians who failed to appreciate “clear signals” and reach a timely diagnosis. But in the clinical context, understanding what conditions underlie those lumps, bleeds, and coughs is often nonlinear. Even experienced clinicians and fully engaged patients may have to pursue multiple possibilities as part of the diagnostic journey, wait to see if symptoms resolve or worsen, or agree to tests or specialty consults that add yet another layer of complexity. Fortunately, in recent years, the dominant strategy for patient safety has shifted from a focus on the actions of an individual to a systems review, to ensure everyone has the right information at the right time so they can make the right decision to support the diagnosis. Limited time and resources—as well as the complexity of human physiology and disease processes— are at the root of human and systemic errors. Clinicians and other practice staff regularly rely upon methods proven to prevent, recognize, or mitigate mistakes. In most circumstances, errors or omissions not immediately recognized or addressed are not crucial to the patient’s long-term health and slip from concern. But even “no harm” events often reveal vulnerabilities that may lead to an impactful, or worse, life-threatening delay in diagnosis and treatment. Historically, many office-based settings lacked the structure and tools to foster a robust culture of safety. Root cause analyses and other forms of informative feedback that have proven effective in the inpatient environment were not routinely built into the clinical office setting. Many incorrect or missed diagnoses were not recognized until the patients had sought care outside the offices where they occurred. Often, the clinicians involved were unaware of the eventual findings until the patient—or a lawyer—asked “How could you have missed this?” DIAGNOSTIC ERROR DIAGNOSTIC ERROR IN THE OFFICE SETTING Focusing on key vulnerabilities and the most frequently missed diagnoses can significantly reduce the frequency of diagnostic error. | HIDDEN IN PLAIN SIGHT | Exposing the Drivers of Diagnostic Error A DOSE OF INSIGHT ® Coverys | ( 6 )