Discrepancy in diagnoses

Why are diagnoses compared?

Comparing ante-mortem and post-mortem conclusions is a key indicator of the quality of care provided by a medical institution and the level of professional competence of physicians. A high percentage of concordance indicates good staff performance and high qualifications. However, discrepancies are inevitable in a certain percentage of cases.

The main goal of such an analysis is to finally clarify the etiology, pathogenesis, and morphogenesis of the disease, as well as to objectively assess the correctness of the administered treatment. The review process takes place in the format of a clinico-pathological conference, where autopsy results are analyzed in detail by a pathologist together with the attending physician.

Setting the correct diagnosis can be hindered by the patient's severe condition, the patient's inadequate assessment of their own symptoms, errors in laboratory or radiological studies, and the physician's insufficient experience.

Causes of diagnostic errors

All factors leading to diagnosis discrepancies are divided into two main groups:

• Objective causes. These are related to circumstances completely beyond the physician's control. They include a short hospital stay, the severity of the condition (including an unconscious state) that makes it impossible to perform necessary examinations, and objective diagnostic difficulty (e.g., in a rare disease or atypical presentation).
• Subjective causes. Directly related to the actions of the medical staff. This may include insufficient examination of the patient despite all available resources, misinterpretation of data (laboratory, radiological) due to lack of knowledge, an erroneous conclusion by an invited consultant, or incorrect formulation of the clinical diagnosis itself.

Categories of diagnostic discrepancy

Discrepancies are classified into 3 categories depending on the nature, causes, and consequences of the error made. When analyzing, discrepancies in the underlying disease, its complications, and the localization of the pathological process must be taken into account. When recording a discrepancy, the physician is obliged to indicate its cause.

1. Category I. Caused exclusively by objective factors. The criteria are a short hospital stay (no more than 3 days) or a severe condition of the patient, making a comprehensive examination impossible.
2. Category II. Causes can be either objective or subjective. The main criterion is that the diagnostic error did not lead to a fatal outcome and did not affect thanatogenesis.

Example of an objective cause: pancreatic head cancer was diagnosed clinically, but autopsy revealed cancer of the major duodenal papilla (symptoms in the terminal stage are identical, the error did not affect the outcome). Example of a subjective cause: in an 82-year-old female patient who stayed in the ward for 60 days, an extensive 3-day-old myocardial infarction was missed against the background of small gastric cancer. The error resulted from negligence (formal rounds, ECG and troponins not ordered). Failing to recognize one of the competing diseases is considered a discrepancy, as each could have caused death.

1. Category III. Characterized by the fact that the diagnostic error entailed incorrect medical management, which led to fatal consequences (death of the patient). It often borders on medical malpractice.

Example: a patient was unsuccessfully treated for interstitial pneumonia with atypical symptoms. A phthisiologist suspected tuberculosis, but the attending physician only partially followed the recommendations (performed a single sputum test) and continued ineffective therapy. Three weeks later, the patient died of tuberculous caseous pneumonia. The error was made without objective reasons, and with correct diagnosis, the outcome could have been favorable.

Class and exam questions

What else to study on this topic

• Rules for formulating and rubricating a pathological diagnosis
• The concept of competing, combined, and background diseases
• Thanatogenesis and mechanisms of death
• Iatrogenic pathologies and their place in the diagnosis structure
• Legal liability of a physician in Category III discrepancies

Other topics in the "Introduction to Nosology" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.