1. JournalYOUR SOURCE FOR PROFESSIONAL LIABILITY EDUCATION AND NETWORKING
April 2015 
Vol. XXVIII 
Number 4
PLUS Journal Reprint
Professional Liability Underwriting Society
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April 2015 PLUS Journal 1
Paul A. Greve, Jr., JD,
RPLU, is Executive
Vice President at
Willis Health Care
Practices. He can
be reached at paul.
greve@willis.com.
P. Divya Parikh is
Director of Research
& Risk Management at
the PIAA. She can be
reached at dparikh@
piaa.us.
Diagnostic Error: Pervasive and Persistent
By Paul A. Greve, Jr., JD, RPLU & P. Divya Parikh MPH
$0
$75,000
$150,000
$225,000
$300,000
$375,000
$450,000
0
2,500
5,000
7,500
10,000
12,500
15,000
Improper
performance
Errors
in
diagnosis
Failure
to
supervise
or
monitor
case
Failure
to
recognize
a
complica@on
of
treatment
Medica@on
errors
Avg
Indemnity
Closed
Claims
Closed
Claims
Avg
Indemnity
Diagnostic Error second by number of closed claims;
Highest by average indemnity payment.
Exhibit 1
The problem of diagnostic error has
gotten more attention than ever over
the last ten years in patient safety and
medical literature. There are hundreds
of articles on a problem that is both
pervasive and persistent. The primary
care specialties have been principally
involved by virtue of the very nature of
their practice.
But closed claim studies by the PIAA
have shown that the problem occurs at
a significant rate in surgical and other
specialties as well. For example, in the
time frame of 2008-2012, data from
the PIAA Data Sharing Project (DSP)
reported that of all the chief medical
factors reported, diagnostic errors
accounted for the second highest
reason for claims and resulted in the
highest average indemnity payments
(See Exhibit 1). Additionally, surgical
specialties were named in 9% of all
closed claims reporting diagnostic
error; hospitalists’ were named in
22%; advanced practice providers
were reported in 24%. Non-surgical
specialties (including primary care
specialties) were reported in 31% of
medical professional liability claims
naming diagnostic error as the chief
medical factor in the claim (See
Exhibit 2).1
In closer review of the diagnostic error
MPL claims reported to the DSP for
this five-year period, radiologists were
most often named in claims, and claims
related to cancer were the top medical
conditions (breast, lung, and colorectal
cancer specifically). Obstetricians/
gynecologists were reported to have the
highest indemnity payments reported
for diagnostic error. And diagnostic
error in cardiac/cardiorespiratory

2. 2 Professional Liability Underwriting Society
conditions saw the top number of claims
reported for this time period followed by
breast cancer, lung cancer, acute myocardial
infarction/heart attack, and colorectal cancer
(See Exhibit 3).
Health care delivery in the United States has
increasingly shifted to outpatient settings.
One study published in 2014 concluded that
the frequency of diagnostic error annually for
adults seen in outpatient settings was 5%. The
authors urged more efforts to measure
diagnostic errors and reduce them.2
Interestingly, in an article published in 2012
in which 1,000 primary care physicians were
surveyed, those participating reported that
more than 5% of their patients were “difficult
to diagnose”.3
An excellent article in the ASHRM Journal in
2014 discussed the challenges of patient safety
in diagnosis. These are “…to identify and
measure diagnostic errors” and “to reduce
both the frequency and severity of errors.”
Prevention of diagnostic error has the potential
to improve with such new tools as decision-
making support software and high-risk
triggers. The author called diagnostic errors
“both frequent and dangerous”.4
Historically, diagnostic error claims usually
involved only physician defendants. The
physician defendant’s personal medical
professional liability policy was responsible for
any payment of indemnity and that was
usually no more than $1M per claim. Hospitals
and health systems were less frequently
culpable in those claims scenarios, absent a
system error or failure to communicate by a
hospital employee. As physicians, especially
primary care physicians, have moved more
often into hospital employment the full limit
of the hospital’s policy is now potentially
exposed for a malpractice claim of diagnostic
error. That is just one more reason for hospital
patient safety and risk management programs
to focus on this significant issue. Doing so will
save lives and save money.
31%
69%
Non-Surgical
9%
91%
Surgical
22%
78%
Hospitalist
24%
76%
Advanced Practice Providers*
*CRNA, PA, SA, NP, Certified Midwife
Diagnostic Error
Other CMF
Exhibit 2
$0
$150,000
$300,000
$450,000
$600,000
0
200
400
600
800
Cardiac
or
cardiorespiratory
arrest
Breast
cancer
Lung
cancer
AMI
Colorectal
cancer
Avg
indemnity
Closed
Claims
Closed
Claims
Avg
Indemnity
Cardiac/Cardiorespiratory arrest most prevalent by closed claims; Cancer
conditions dominated top diagnostic error claims.
Exhibit 3
Endnotes
1 PIAA Data-Sharing Project, 2014.
2 Singh, Hardeep, et al. ‘The frequency of diagnostic errors in outpatient care:
estimations from the three large observational studies involving US adult
populations. BMJ Qual Saf. April 2014. http://qualitysafety.bmj.com.content/
early/2014/4/05/05/bmjqs-2013-002627.full (accessed February 11, 2015).
3 Sarkar, U et al.“Challenges of making a diagnosis in the outpatient setting: a multi-
site survey of primary care physicians”. BMJ Qual Saf 2012; 21: 641-648.
4 Groszkruger, Dan. “Diagnostic error: untapped potential for improving patient
safety?” Journal of Healthcare Risk Management 2014; Vol. 34; No.1. 38-43.