Numerous ICU Deaths Have Missed Diagnoses

A new study suggests that more than a quarter of adult patients in intensive care units (ICUs) each year die with a misdiagnosis, including those with a potentially fatal major missed diagnosis.

Researchers at Johns Hopkins University (JHU; Baltimore, MD, USA) conducted a systematic meta-analysis of 31 studies that examined autopsy-confirmed diagnostic errors in the adult ICU; a median of 43% of the deaths that occurred during the study period were autopsied. In all, 5,863 autopsies were abstracted for autopsy rate, misdiagnosis prevalence, Goldman error class, and diseases misdiagnosed. Studies analyzing misdiagnosis of one specific disease were excluded. The prevalence of Class I (potentially lethal) misdiagnoses were calculated as a nonlinear function of the autopsy rate.

The results showed that the prevalence of misdiagnoses ranged from 5.5–100%, with 28% of autopsies reporting at least one misdiagnosis and 8% identifying a Class I diagnostic error, such as pulmonary embolism (PE) or myocardial infarction (MI). The projected prevalence of Class I misdiagnoses for a hypothetical autopsy rate of 100% was 6.3%. Vascular events and infections were the leading lethal misdiagnoses (41% each). The most common individual Class I misdiagnoses were PE, MI, pneumonia, and aspergillosis. The study was published in the November 2012 issue of BMJ Quality and Safety.

“The 8% rate of major and potentially lethal ICU misdiagnoses is higher than the 5% rate of lethal misdiagnoses documented in the general hospital population,” said lead author Bradford Winters, MD, PhD, an associate professor of anesthesiology and critical care medicine. “The difference can be attributed to ICU-specific factors such as the inability of patients to communicate their medical history during the workup process and limited staff resources leading to ‘competition for care’.”

The Goldman Classification, widely used for autopsy findings, defines class I errors as “missed major misdiagnoses with potential adverse impact on survival and that would have changed management.” Class II errors are defined as missed major diagnoses that would not have affected survival or altered the course of care. Class III and class IV errors are defined as misdiagnoses related to the terminal disease but not related to death or unrelated to both disease and death, respectively.

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