Diagnostic Error in General Surgery: Cognitive Bias and Systems Issues in Medical Malpractice Claims (Abstract)

Jacqueline Ross, RN, PhD, Coding Director, Department of Patient Safety and Risk Management

Although claims against general surgeons primarily allege technical surgical-type errors, diagnostic error is the second most frequent allegation against or case type for general surgeons. Analysis of malpractice claims can elucidate the causes of and solutions to diagnostic errors. This study considers differences between diagnostic errors, both cognitive and systemic, committed by general surgeons in the inpatient vs. the outpatient setting.

Study Design

This was a cross-sectional analysis of 203 closed medical malpractice claims from The Doctors Company database using the CRICO Comprehensive Risk Intelligence Tool. Analysis was descriptive for the characteristics of claims based on years, type of patient (inpatient, outpatient), severity, final diagnosis, and contributing factors. The CRICO diagnostic process of care framework was used to examine diagnostic error by general surgeons. Chi-square was used to determine potential differences between inpatient and outpatient settings.


  • Significant differences emerged between inpatient and outpatient settings considering the following factors leading to claims:
    • Communication between providers regarding the patient’s condition was more likely a factor in the inpatient setting.
    • Delay or failure to consult was more likely a factor in the inpatient setting.
    • Failure to appreciate signs, symptoms, and/or test results was more likely a factor in the inpatient setting.
  • In the outpatient setting, many of the claims involved delayed biopsies based on symptoms or recommendations from radiologists. A higher percentage of patients in the outpatient setting did not adhere to plans for follow-up care, including not returning calls or missing appointments.
  • More than two-thirds of claims studied involved high-severity injuries.
  • The final correct diagnoses were overwhelmingly related to postoperative complications.


Decreasing diagnostic error is feasible. Clinical judgment and communication remain among the top contributing factors involved in medical malpractice claims, as this study’s findings confirmed. It’s crucial to understand where the breakdowns in communication are occurring so interventions can be implemented, because the lack of communication can influence so much along the diagnostic process of care, from the start of taking the patient’s history to the patient’s nonadherence to the plan of care.

Many of the contributing factors involved clinical judgment. Sometimes relying on intuition included cognitive bias, which led a general surgeon to focus on the wrong diagnosis or to failure or delay in ordering a diagnostic test. Use of a clinical guideline or a clinical decision-support system can enable providers to decrease the variability in their response patterns.

The diagnoses often missed by general surgeons, especially those leading to high-severity injuries, include malignancies, vascular events, and infections. General surgeons should consider all possibilities in the post-operative management phase.


The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.