title: Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims.
abstract: OBJECTIVE
  To erform a process analysis of missed and delayed diagnoses of breast and colorectal cancers to identify: (1) the cognitive and logistical factors that lead to these diagnostic errors, and (2) prevention strategies.
  
  
  METHODS
  Using 56 cases (43 breast, 13 colon) of missed and delayed diagnosis, we performed structured analyses to identify specific points in the diagnostic process in which errors occurred. Each error was classified as either a cognitive error or logistical breakdown. Finally, two physician-investigators identified strategies to prevent the errors in each case.
  
  
  RESULTS
  Virtually all cases involved one or more cognitive errors (53/56, 95 %) and approximately half (31/56, 55 %) involved logistical breakdowns. The clinical activity most prone to cognitive error was the selection of the diagnostic strategy, both during the office visit (25/56, 45 %) and during interpretation of test results (22/50, 44 %). Arrangement of follow-up visits with a primary care physician (8/29, 28 %) or specialist physician (7/29, 26 %) were especially prone to logistical breakdowns. Adherence to current clinical guidelines could have prevented at least one error in 66 % of cases and assistance from a patient advocate could have prevented at least one error in 48 % of cases.
  
  
  CONCLUSIONS
  Cognitive errors and logistical breakdowns are common among missed and delayed diagnoses of breast and colorectal cancers. Prevention strategies should focus on ensuring improving the effectiveness and use of clinical guidelines in the selection of diagnostic strategy, both during office visits and when interpreting test results. Tools to facilitate communication and to ensure that follow-up visits occur should also be considered.
authors.affiliation: Division of General Medicine and Primary Care, Department of Medicine, Brigham & Women's Hospital, 3/F 1620 Tremont Street, Boston, MA, 02120, USA. epoon@partners.org
authors.forename: Eric G
authors.initials: EG
authors.lastname: Poon
authors.forename: Allen
authors.initials: A
authors.lastname: Kachalia
authors.forename: Ann Louise
authors.initials: AL
authors.lastname: Puopolo
authors.forename: Tejal K
authors.initials: TK
authors.lastname: Gandhi
authors.forename: David M
authors.initials: DM
authors.lastname: Studdert
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000175:diagnosis*; D003071:Cognition; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D003661:Decision Support Techniques; D057210:Delayed Diagnosis / Q000517:prevention & control / Q000523:psychology / Q000706:statistics & numerical data*; D003951:Diagnostic Errors / Q000517:prevention & control / Q000523:psychology / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008318:Malpractice / Q000706:statistics & numerical data*; D008875:Middle Aged