Types of diagnostic errors in neurological emergencies in the emergency department

Neurological emergencies often pose diagnostic challenges for emergency physicians because these patients often present with atypical symptoms and standard imaging tests are imperfect. Misdiagnosis occurs due to a variety of errors. These can be classified as knowledge gaps, cognitive errors, and systems-based errors. The goal of this study was to describe these errors through review of quality assurance (QA) records.

This was a retrospective pilot study of patients with neurological emergency diagnoses that were missed or delayed at one urban, tertiary academic emergency department. Cases meeting inclusion criteria were identified through review of QA records. Three emergency physicians independently reviewed each case and determined the type of error that led to the misdiagnosis. Proportions, confidence intervals, and a reliability coefficient were calculated.

During the study period, 1168 cases were reviewed. Forty-two cases were found to include a neurological misdiagnosis and twenty-nine were determined to be the result of an error. The distribution of error types was as follows: knowledge gap 45.2% (95% CI 29.2, 62.2), cognitive error 29.0% (95% CI 15.9, 46.8), and systems-based error 25.8% (95% CI 13.5, 43.5). Cerebellar strokes were the most common type of stroke misdiagnosed, accounting for 27.3% of missed strokes.

All three error types contributed to the misdiagnosis of neurological emergencies. Misdiagnosis of cerebellar lesions and erroneous radiology resident interpretations of neuroimaging were the most common mistakes. Understanding the types of errors may enable emergency physicians to develop possible solutions and avoid them in the future.