Institute of Medicine Report Examines Medical Misdiagnoses


In the latest report in its series on quality and patient safety in healthcare, the Institute of Medicine addresses the challenge of errors in medical diagnoses.

Authors of the IOM’s “Improving Diagnosis in Health Care” report cite problems in communication and limitations in electronic health records behind inaccurate and delayed diagnoses, concluding that the problem of diagnostic errors generally has not been adequately studied.1

“This problem is significant and serious. Yet we don’t know for sure how often it occurs, how serious it is, or how much it costs,” said the IOM committee’s chair, John Ball, MD, of the American College of Physicians, in a prepared statement. The report concludes there is no easy fix for the problem of diagnostic errors, which are a leading cause of adverse events in hospitals and of malpractice lawsuits for hospitalists, but calls for a major reassessment of the diagnostic process.2

Hospitalist Mangla Gulati, MD, FACP, SFHM, assistant chief medical officer at the University of Maryland Medical Center in Baltimore, says hospitalists would be remiss if they failed to take a closer look at the IOM report. “Diagnostic error is something we haven’t much talked about in medicine,” Dr. Gulati says. “Part of the goal of this report is to actually include the patient in those conversations.” Patients who are rehospitalized, she says, may have been given an incorrect initial diagnosis that was never rectified, or there may have been a failure to communicate important information.

“How many tests do we order where results come back after a patient leaves the hospital?” asks Kedar Mate, MD, senior vice president at the Institute for Healthcare Improvement and a hospitalist at Weill Cornell Medicine in New York City. “How many in-hospital diagnoses are made without all of the available information from outside providers?”

One simple intervention hospitalists could do immediately, he says, is to start tracking all important tests ordered for patients on a board in the medical team’s meeting room, only removing them from the board when results have been checked and communicated to the patient and outpatient provider.


  1. National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. 2015.
  2. Saber Tehrani AS, Lee HW, Mathews SC, et al. 25-year summary of U.S. malpractice claims for diagnostic errors 1986–2010: An analysis from the National Practitioner Data Bank. BMJ Qual Saf. 2013 Aug; 22(8):672–680.

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