The National Academy of Medicine defines diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” Office-based practices are the predominant setting for malpractice claims related to diagnostic error.

Yes, office-based care settings.

Fast-paced, high-acuity emergency departments (EDs) have fewer malpractice claims related to diagnostic error than physician offices, according to recent research. Furthermore, 53 percent of those claims had indemnity payments that averaged $661,000; more than twice the payment for non-diagnosis-related claims.

So, why do office-based practices appear to be particularly vulnerable to diagnostic error? Let’s examine the data to uncover potential areas of exposure and, more importantly, look at what can be done to mitigate the risk.

Underappreciated problem

You’re not alone if office-based practices don’t strike you as particularly high-risk care settings. They’re typically associated with less acute situations, lower-risk procedures, methodical processes, and a more structured pace than most EDs or inpatient settings. Additionally, office-based primary care providers (PCPs) often have a more comprehensive understanding of their patients’ health due to their longstanding relationships.

Nevertheless, recent data analysis of 6,009 medical malpractice events closed from 2020-2024 revealed that offices/clinics had the most diagnosis-related malpractice events and the highest indemnity; specifically, 34 percent of the malpractice events and 38 percent of indemnity paid. EDs/urgent care settings ranked second, with 29 percent of the malpractice events and 26 percent of indemnity paid.

Cancer diagnoses accounted for close to half (45 percent) of the missed diagnosis allegations. Prostate, lung, breast, and colorectal cancers topped the list; all of which are perceived as “detectable” by the general public.

Key vulnerabilities

The fact that practices may experience less “controlled chaos” than EDs doesn’t necessarily equate to less risk. There are misperceptions about the diagnostic process itself. Important to note is that:

• The diagnostic process is complicated: The process involves multiple steps, but diagnostic failures are seldom due to missing just one step. Instead, physical signs and symptoms may develop slowly and non-linearly; only in hindsight are they “clear signals” of disease.
• Both systems and humans are prone to error: Every practice faces time and resource limitations. For instance, few practices have the resources to incorporate safety-related processes and tools commonly used to manage acute conditions in inpatient settings, such as diagnostic time-outs and root cause analysis. Additionally, physicians’ intuitive thinking and cognitive biases may come into play. Patients may contribute, as well, as they may be reluctant to follow through on critical follow-up testing, especially if they’re afraid of receiving potentially bad news, like a cancer diagnosis.

Mitigation strategies

Fortunately, examining these vulnerabilities in more detail can provide insight into effective risk-reduction strategies. Steps that practices may want to consider to strengthen the diagnostic process include:

• Updating family history and clinical details at every patient visit: Taking a history and performing a physical assessment (H&P) are foundational parts of an office-based diagnosis. However, the data revealed that H&P issues are involved in almost half (49 percent) of malpractice events and 41 percent of the indemnity paid. One of the biggest opportunities for reducing diagnostic error is to enhance the initial patient H&P.
• Raising awareness of potential cognitive biases: Creating a robust safety culture encourages providers to examine potential cognitive biases objectively and critically. Anchoring bias or confirmation bias, for example, might cause physicians to inadvertently rely too heavily on initial impressions, thereby narrowing their diagnostic focus. While intuitive thinking based on experience and knowledge is a critical aspect of patient care, it should be only one part of a structured, analytical diagnostic framework. In office settings, physicians can use clinical decision support (CDS) tools embedded in the electronic health record (EHR) to help support the diagnostic thought process.
• Delivering diagnostic uncertainty with confidence: It’s OK not to have definitive answers immediately; however, physicians must explain and document why they’re pursuing, or not pursuing, potential diagnoses. Implementing processes such as a diagnostic time-out to ensure that all relevant information and perspectives have been considered when uncertainty exists reduces diagnostic error.
• Involving patients in implementing orders from the outset: Alleged failure to order appropriate diagnostic tests or specialty referrals is involved in 30 percent of diagnosis-related office malpractice events. Adding CDS tools and automatic EHR alerts can support the ordering and tracking of appropriate diagnostic tests, screenings, and consultations. Documentation of all discussions regarding the importance of follow-up with these tests and referrals will engage patients at the onset. Patients play an important role in this process. Using plain language helps engage patients by describing why the test or referral is important, how to prepare for it, what it entails, and what results they might see.
• Ensuring timely follow-up: Failures or delays in patient follow-up are responsible for 11 percent of diagnosis-related malpractice claims and 14 percent of indemnity paid. Often, it’s a systems issue when patient follow-up slips through the cracks. Establishing clear procedures that designate who is responsible for test follow-up, outline the required notification timeline, and specify how physicians and patients should be notified is a key component of risk reduction.

Reduce risk together

A recent medical malpractice claims data analysis revealed that office-based settings are the most susceptible to malpractice claims alleging diagnostic error. A deep dive into the data revealed several steps office-based practices can take to lessen their vulnerabilities. From administrative staff to clinical specialists, everyone must work together to ensure that critical information is conveyed in an appropriate and timely manner to reach an accurate diagnosis. Patients must be actively engaged, and conversations well-documented. By taking steps to address the underlying causes of diagnostic errors, practices can enhance patient safety and mitigate malpractice risks.

Susan L. Montminy and Marlene Icenhower are health care executives.