Diagnostic errors―delays and misses―are a perennial driver of medical professional liability claims. Candello, a national organization that collects and analyzes malpractice claims data, reviewed 6,544 general medicine cases closed between 2014 and 2023. In 46 percent of these cases, diagnostic failure was the primary allegation, with missed or delayed diagnosis of cancer cited most frequently. This study found that a series of problems―rather than one dramatic event―contributed to the ultimate delay in or failure to diagnose cancer, including failure to appreciate concerning symptoms; failure to appreciate the significance of test results; follow-up deficiencies; poor communication; and inadequate documentation.¹
The following example illustrates how a combination of factors can delay diagnosis and treatment.
Delayed Diagnosis of Laryngeal Cancer
A 45-year-old female patient with a history of reflux disease (GERD) presented to her primary care physician (PCP) in February of 2023 with complaints of recent hoarseness, dysphagia, sore throat, and weight loss. She saw a gastroenterologist the year before for workup of GERD and possible esophagitis. At that time, an upper endoscopy (EGD) showed reflux changes, and the gastroenterologist prescribed a proton pump inhibitor (PPI). When the patient saw her PCP, she reported that she had not found relief from the medication and had stopped taking it. The PCP referred the patient to an otolaryngologist (ENT), and an appointment was scheduled.
When the patient saw the ENT in April of 2023, she relayed her history of GERD. The ENT indicated he had reviewed the gastroenterologist’s notes and proceeded with examination. A flexible laryngoscopy was performed and right vocal cord paralysis and some inflammation were noted; no biopsy was performed. The ENT ordered a CT scan and performed a videostroboscopy. The CT scan report described soft tissue “thickness,” and the videostroboscopy showed an area of inflammation. The ENT diagnosed laryngopharyngeal reflux and recommended the patient resume taking the PPI.
Over the next three months, the patient continued to experience worsening vocal changes, labored breathing, and dysphagia. She returned to the ENT in July and underwent a repeat laryngoscopy, which showed the right vocal cord remained paralyzed. The ENT added albuterol for relief of symptoms attributed to asthma. Although a follow-up visit with the ENT was scheduled for one month later, the patient cancelled the appointment without rescheduling.
In December of 2023, the patient established care with a new ENT. She complained of persistent hoarseness, tiredness, and shortness of breath. The ENT performed flexible laryngoscopy and ordered a biopsy and imaging, which revealed Stage III laryngeal squamous cell carcinoma. The new ENT also reviewed the patient’s prior records and noted that the inflammation on the videostroboscopy from April was suggestive of a mass. The patient underwent a laryngectomy, chemotherapy, and radiation, and required a permanent tracheostomy. She sued the first otolaryngologist and radiologist, alleging delayed diagnosis of cancer resulting in loss of her natural voice and reduced life expectancy.
The patient/plaintiff’s case centered on failure to adequately investigate and follow up on red flags: hoarseness, dysphagia, vocal cord paralysis, weight loss, and progressive respiratory symptoms. Experts felt that the patient’s history of GERD created an “anchoring bias” that traveled with the patient over subsequent evaluations. Experts were critical that the first ENT did not biopsy or otherwise definitively evaluate suspicious laryngeal findings. The ENT also failed to document why a biopsy was not indicated. They also opined that the videostroboscope and CT results were underappreciated. The first radiologist minimized the CT findings as soft tissue thickness and did not note a suspicion of cancer. This radiology report, in turn, influenced how the ENT approached the case and contributed to his not pursuing an explanation for the patient’s symptoms.
Risk Management Opportunities
This scenario presents several high-risk failure points involving diagnostic anchoring, inadequate follow-up of persistent symptoms, communication gaps, and inadequate documentation.
Be Aware of Cognitive Biases
“Anchoring” is a common cognitive bias. It occurs when clinicians focus on a particular piece of information early in the patient workup and fail to incorporate subsequent information or impressions. When a patient presents with a particular complaint or working diagnosis, it can lead physicians to a premature conclusion that such initial findings explain symptoms.2,3,4 Taking this narrow path can, unfortunately, lead nowhere―until it’s too late. Here are some recommendations to manage risk:
- Establish a differential diagnosis. Ask yourself, “What else could this be?” “What is the worst thing it could be?”
- Consider taking a diagnostic “timeout”; run through a checklist before finalizing benign diagnoses. Your electronic health record (EHR) might offer some support with diagnosis templates or prompts for persistent, unresolved symptoms. As with any template, be sure to review and tailor it to the specific patient before finalizing a note.
- Consider that the patient could have concurrent conditions.
- Solicit colleague feedback in exploring alternative diagnoses for persistent symptoms.5
- Remember that rushing to judgment can lead to a missed abnormality. Try deliberately slowing down to consider alternative diagnoses.5
- Review the medical record with a fresh eye to catch and track unresolved abnormal findings.
Documentation
Documentation should support patient care and, in the event of an adverse outcome, demonstrate the defensibility of that care. Elements of strong documentation include:
- The physician’s analysis and thought process (e.g., why malignancy is or is not suspected; reason for deferring biopsy)
- Discussion of differential diagnoses
- Follow-up instructions
- Advice about what symptoms the patient should look for and action to take (e.g., immediate return
if hoarseness persists) - Planned reassessment timeline
For Radiology
The CT interpretation by the first radiologist described soft tissue “thickness,” which was deemed ambiguous. Appreciate the importance of:
- Using clear language when malignancy cannot be excluded
- Including actionable recommendations; e.g.:
- Direct visualization/biopsy recommended”
- “Correlation with laryngoscopy advised”
- “Short-interval follow-up suggested”
- Documenting whom you notified; date/time of communication; and clinical urgency
Coordination of Care
The PCP appropriately referred the patient to an ENT, but there may have been a missed opportunity for coordination of care and addressing the patient’s persistent symptoms. Specialists should ensure that the patient’s PCP receives specialist reports promptly, and the PCP should track unresolved referrals.
Follow-Up
When patients cancel appointments without rescheduling:
- Ensure physician review of cancellations and no-shows to determine urgency of outreach for follow-up. Instruct staff to contact patients with a phone call and to document results of call attempts.
- If there is no response, send a letter by certified and regular mail to communicate the need for follow-up, the recommended timeframe, and the potential consequences of not following up.
- In cases of persistent, unresolved symptoms, implementing risk management strategies early, and along the continuum care, can improve outcomes and reduce liability for physicians.
Jane Mock, CPHRM, is a Senior Risk Management and Patient Safety Specialist. Questions or comments related to this article should be directed to JMock@CAPphysicians.com.
References
¹Tremont, H. “Strategies for Patient Safety: Cancer Prevention Awareness and the Reality of Diagnostic Risk.” 2026. Candello. https://www.rmf.harvard.edu/News-and-Blog/Newsletter-Home/News/2026/Feb…
²Ly, D.P., Shekelle, P.G., & Song, Z. 2023. “Evidence for Anchoring Bias During Physician Decision-Making.” JAMA internal medicine, 183(8), 818–823. https://doi.org/10.1001/jamainternmed.2023.2366
³Lee, J.H., Mo, B., & Markar, J. 2025. “Cognitive Bias in Action: Delayed Diagnosis of Thoracic Meningioma Mimicking Lumbosacral Radiculopathy-A Case Report.” Clinical case reports, 13(9), e70867. https://doi.org/10.1002/ccr3.70867
4 Cherin, N., Patel, S., & Jukic, M. 2024. “Delayed amyotrophic lateral sclerosis diagnosis with subtle cardiac manifestations: Was anchoring bias contributory?” Clinical case reports, 12(2), e8544. https://doi.org/10.1002/ccr3.8544
5 Smith, T.M. 2021. “Four Widespread Cognitive Biases and How Doctors Can Overcome Them.” American Medical Association. https://www.ama-assn.org/about/ethics/4-widespread-cognitive-biases-and-how-doctors-can-overcome-them