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Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / Singhal, Geeta / McDonald, Kathryn / Singh, Hardeep / Newman-Toker, David

Editorial Board: Basso , Daniela / Crock, Carmel / Croskerry, Pat / Dhaliwal, Gurpreet / Ely, John / Giannitsis, Evangelos / Katus, Hugo A. / Laposata, Michael / Lyratzopoulos, Yoryos / Maude, Jason / Sittig, Dean F. / Sonntag, Oswald / Zwaan, Laura

CiteScore 2018: 0.69

SCImago Journal Rank (SJR) 2018: 0.359
Source Normalized Impact per Paper (SNIP) 2018: 0.424

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Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database

Ava L. Liberman
  • Corresponding author
  • Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Stern Stroke Center, 3316 Rochambeau Avenue, 4th Floor, Bronx, NY 10467, USA
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Jillian Skillings / Penny Greenberg / David E. Newman-Toker
  • Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
  • Departments of Epidemiology and Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Dana Siegal
Published Online: 2019-07-11 | DOI: https://doi.org/10.1515/dx-2019-0031



Misdiagnosis of dangerous cerebrovascular disease is a substantial public health problem. We sought to identify and describe breakdowns in the diagnostic process among patients with ischemic stroke to facilitate future improvements in diagnostic accuracy.


We performed a retrospective, descriptive study of medical malpractice claims housed in the Controlled Risk Insurance Company (CRICO) Strategies Comparative Benchmarking System (CBS) database from 1/1/2006 to 1/1/2016 involving ischemic stroke patients. Baseline claimant demographics, clinical setting, primary allegation category, and outcomes were abstracted. Among cases with a primary diagnosis-related allegation, we detail presenting symptoms and diagnostic breakdowns using CRICO’s proprietary taxonomy.


A total of 478 claims met inclusion criteria; 235 (49.2%) with diagnostic error. Diagnostic errors originated in the emergency department (ED) in 46.4% (n = 109) of cases, outpatient clinic in 27.7% (n = 65), and inpatient setting in 25.1% (n = 59). Across care-settings, the most frequent process breakdown was in the initial patient-provider encounter [76.2% (n = 179 cases)]. Failure to assess, communicate, and respond to ongoing symptoms was the component of the patient-provider encounter most frequently identified as a source of misdiagnosis in the ED. Exclusively non-traditional presenting symptoms occurred in 35.7% (n = 84), mixed traditional and non-traditional symptoms in 30.6% (n = 72), and exclusively traditional in 23.8% (n = 56) of diagnostic error cases.


Among ischemic stroke patients, breakdowns in the initial patient-provider encounter were the most frequent source of diagnostic error. Targeted interventions should focus on the initial diagnostic encounter, particularly for ischemic stroke patients with atypical symptoms.

Keywords: diagnostic error; ischemic stroke; malpractice claims

Subject terms: diagnosis; ischemic stroke; emergency department


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About the article

Corresponding author: Ava L. Liberman, MD, Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Stern Stroke Center, 3316 Rochambeau Avenue, 4th Floor, Bronx, NY 10467, USA, Phone: +(718) 920-6444, Fax: +(718) 654-0364

Received: 2019-04-09

Accepted: 2019-06-10

Published Online: 2019-07-11

Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: Research reported in this publication was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health under Award Number K23NS107643. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr. Newman-Toker’s effort was supported by the Armstrong Institute Center for Diagnostic Excellence. No financial support for this study was provided by contract with any other agency, foundation, company, institute, or philanthropic foundation.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

Conflicts of interest: ALL, JS, PG, and DS report no conflicts of interest. Dr. Newman-Toker has conducted government and foundation funded research related to diagnostic error, dizziness, and stroke. He has been loaned research equipment related to diagnosis of dizziness and stroke by two commercial companies (Natus/Otometrics and Interacoustics) and Johns Hopkins has licensed related diagnostic decision-support technology to Otometrics for which Dr. Newman-Toker has received a royalty payment; he occasionally serves as a paid consultant, reviewing medicolegal cases for both plaintiff and defense firms related to misdiagnosis of neurological conditions, including dizziness and stroke.

Citation Information: Diagnosis, 20190031, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2019-0031.

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