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Diagnostic errors (DEs) remain an understudied component of health care quality and safety.1 As defined by the National Academy of Medicine, a DE is “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.”2 Diagnostic errors can have grave consequences for patients, resulting in an estimated 40,000 to 80,000 hospital deaths per year and accounting for a majority of malpractice claims in the United States.3,4 Given that current estimates predict that most individuals will experience at least 1 DE in their lifetime, grasping a better understanding and creating strategies to mitigate harm could have a pervasive impact on improving patient safety outcomes.5
Diagnostic errors have been known to plague the dental profession. In a retrospective review of 182 published case reports in dentistry, 23% of experiences were categorized as delayed appropriate treatment, disease progression, or unnecessary treatment associated with misdiagnoses.6 Research has also demonstrated that the lack of timely referrals by dentists is a major contributing factor to the delayed diagnoses of oral cancer.7,8 Understanding dental diagnostic failures (DDFs) is further complicated by the profession’s failure to use standard dental diagnostic codes and document such occurrences in electronic dental records.9 The field of dentistry faces unique challenges with formulating proper diagnoses, as perceptual dispositions of imaging procedures, high patient volume, and incomplete patient histories make dentists more susceptible to DDFs.10
Despite the dearth of research available on DE, patients are apprehensive about the prevalence of such occurrences. In a survey of more than 2000 patients, 1 in 4 Americans reported experiencing a DE either personally or by someone close to them.11 Therefore, understanding the patient’s perspective is a crucial step toward remedying this multifactorial challenge. The primary goal of this study was to understand the perception of patients who have experienced a DDF and identify patient-centered strategies to help reduce future occurrences.
METHODS Study DesignWe conducted an in-depth qualitative study comprising an initial screening assessment, followed by subsequent patient interviews for qualifying participants. The social media platform, Facebook, was used to recruit participants via nationwide advertisements created in collaboration with the University of California San Francisco Participant Recruitment Program (Fig. 1). The advertisement was shown to almost 140,000 Facebook users, receiving a total of 3125 clicks (average cost per click was $0.39). A total of 756 participants responded to the screening survey (24.2% conversion rate; Fig. 2), yielding 396 potentially eligible study participants who were invited to complete an initial assessment survey. A total of 161 participants provided written descriptions of their DDF experience, 67 comprehensive interviews were completed, and they were provided with a $10 or $20 gift card (Fig. 3). Of the 67 transcribed interviews studied, 55 were determined to be a true DDF experiences. The study was approved by the University of California San Francisco Human Research Protection Program (IRB No. 20-31017).
FIGURE 1: Facebook advertisement used for DDF study recruitment.
FIGURE 2: Responses to screening survey.
FIGURE 3: Flowchart of participant response.
Screening Survey, Initial Assessment Survey, and Interview GuideThe survey and interview questions used in this study were heavily informed by previous research studies on medical DE.12–14 All questions were refined by a panel of 8 nondental professionals. A plain language expert also reviewed the questions to ensure readability and easy comprehension by patients. The screening survey was administered through Qualtrics and captured patient experiences that were potentially associated with dental DE (Supplemental A, https://links.lww.com/JPS/A606). Patients were invited to participate if they spoke English as a primary language, had attended a dental appointment within the last 3 years (since January 2019), and experienced either a misdiagnosis, missed diagnosis, or delayed diagnosis by a dentist, or had unexplained symptoms. Eligible participants were then assessed for details regarding their DDF experience. Patients provided demographic details (race and ethnicity, age, gender, and household income) and contact information for follow-up interviews (Table 1). The interview guide comprised 4 main sections, with probe questions designed to capture pertinent information (Supplemental B, https://links.lww.com/JPS/A606). Interviews were conducted by a single interviewer (L.C.V.), verbal consent was obtained at the beginning of each call, and all calls were audio recorded.
TABLE 1 - Demographic Distribution of Interviewed Study Participants Characteristic Count (n) % Total 55 — Sex Male 18 67.3 Female 37 32.7 Age, y 18–24 2 3.6 25–34 8 14.5 35–44 22 40.0 45–54 6 10.9 55–64 10 18.2 >64 7 12.7 Ethnicity Hispanic/Latino 5 9.1 Black/African American 18 32.7 Middle Eastern or Northern African 0 0 White 23 41.8 Asian 8 14.5 AI/AN/NH/OPI 0 0 Unknown 1 1.8 Yearly household income in 2019, $ ≤50,000 29 52.7 50,001–100,000 18 32.7 101,001–150,000 6 10.9 >150,000 2 3.6Audio recordings were de-identified, transcribed by Rev.com, and managed using Dedoose, a cloud-based software. A hybrid thematic analysis approach was used to capture details about 4 main domains of interest, including the patient’s initial DDF experience, contributing factors, impact, and strategies to mitigate future occurrences (deductive approach).15 To ensure reliability and transparency of data, 2 reviewers (R.H., L.C.V.) independently coded the transcripts into the 4 domains and themes that were jointly developed by the research team (Supplemental C, https://links.lww.com/JPS/A606). Reviewers also created new codes and themes as they reviewed the transcripts (inductive approach). Any discrepancies with coding were resolved by a third reviewer (E.O.-U.). Each theme was summarized using codes and illustrative quotes from participants (Tables 2–5).
TABLE 2 - Patient Experiences of DDFs Domain Theme Illustrative Quotes Patient experience (1) Clinical presentation: symptoms and complaints that promoted patient’s desire to seek dental care - “I had this toothache. It wouldn’t go away.”—P29Each participant was asked to describe their DDF experience in their own words. Five major themes were assessed including clinical presentation, initial diagnosis and treatment, sequalae, correct diagnosis, and concurrent treatment errors (Table 2).
Clinical Presentation (Theme 1)Diagnostic error experiences were commonly catalyzed by an ailment or concern of the patient. Common symptoms that prompted patients’ initial clinical evaluation included toothache/pain within the oral cavity, tooth sensitivity, swollen/inflamed gums, chipped or cracked tooth, bleeding within the oral cavity, and facial pain outside of the oral cavity. In cases where patients presented asymptomatic, the DDF was the result of an incidental finding during a routine preventive dental checkup.
Initial Diagnosis and Treatments (Theme 2)In addition to receiving an oral examination, dentists most frequently performed x-rays before postulating patient diagnoses. Although less common, in some cases, dentists ordered cone beam computed tomography images or performed thermal pulp tests when pulp necrosis was included in differentials. The top initial diagnoses were dental caries and gingivitis/periodontal disease. A majority of patients diagnosed with dental caries belonged to the youngest age range studied, 18 to 24 years olds. About one-quarter of participants failed to receive a diagnosis or were told by their provider that no pathology/disease was present, leading to delayed diagnoses. Notably, all individuals who failed to receive an initial diagnosis had a household income of $100,000 or less. Some initial treatments provided to patients most commonly included new medication prescriptions or dental fillings. Among patients who received medication, antibiotics were the most frequently prescribed. For participants who expressed experiencing a great degree of pain, palliative treatment was sometimes provided in the form of analgesics. In addition to traditional treatments, many patients were “prescribed” a personal improvement in oral hygiene or received deep cleaning.
Sequalae (Theme 3)Some of the most prominent consequences patients faced included prolonged suffering, disease progression, unnecessary treatments, and the development of new symptoms or comorbidities. The most reported new symptom developed was infection/development of an abscess. Throughout the DE experience, many patients received 2 or more referrals or second opinions, and some reported experiencing multiple DE before receiving a correct diagnosis.
Correct Diagnosis (Theme 4)Most DDF experiences lasted less than 6 months before the patient received a correct definitive diagnosis. It was uncommon for a DE to last more than 5 years, although this did unfortunately occur for a minority of participants. The most common test performed that led health care professionals to the correct diagnosis was x-rays, although a thorough patient history and clinical examination also played a crucial role in detecting the initial DE. The top correct diagnoses included pulp necrosis, dental abscess, periodontal/gum disease, caries, and cracked/chipped tooth. Unfortunately, almost one-quarter of participants reported that their DE remained unresolved with no definitive diagnosis. There were also a few cases where it was determined that no pathology or disease was ever present. In most of these situations, patients were told that they had sensitive teeth, or the dentist performed x-rays and admitted that they could not find anything wrong. Although some cases required a dental specialist, such as an endodontist or oral surgeon, to detect DE, most cases were resolved by another general dentist. Some of the initial DEs were also made by physicians before referral to a dentist. The most common treatments provided after correct diagnoses were established included tooth extraction/implant removal, root canal therapy, new medication or adjustment to prior medication regimen, and tooth crowns or prosthesis.
Concurrent Treatment Error (Theme 5)An unanticipated finding of this study was the significant amount of patients who also experienced a concurrent treatment error during their DE experience that potentially led to additional harm. More than one-third of participants experienced treatment error, and most were executed by the same dentist who made the initial DE. Similar to other financial trends previously noted in this domain, all patients who experienced a treatment error had an annual income of $100,000 or less.
Domain 2: Contributory Factors to DDFsIn this domain, participants shared their perspective on factors they believe contributed to the DE and were asked to determine culpability and decide whether the DE was a preventable occurrence. The 5 themes used to assess these initiatives included clinical influences, patient influences, system influences, fault attribution, and DE prevention (Table 3).
Clinician Influences (Theme 1)Participants provided numerous observations about their provider that they believe contributed to the development of the DE. Poor communication, inadequate time with patients, and financial incentives were the most prevalent concerns regarding the culpable dentist. Patients frequently reported that their dentist seemed rushed, working hastily to get through crowded waiting rooms. It was most common for younger participants (34 years and younger) to report providers spending insufficient time with them. Inadequate time also seemed to negatively impact the patient-clinician relationship and the ability to properly educate patients. In addition, many participants also addressed concerns regarding deficient clinician knowledge and inexperience. When discussing their dentist’s age, participants expressed discomfort with both clinicians that appeared too young and too old.
Patient Influences (Theme 2)Participants provided personal reflections regarding how their role as the patient could have contributed to the development of a DE. Patients cited concerns about lack of self-advocacy, poor choice in provider/clinic, and lack of dental health literacy. Many patients who reported a lack of self-advocacy expressed concerns about being too timid to speak up because of their lack of dental knowledge. Interestingly, female participants were almost 3 times more likely than male participants to fault themselves for lack of self-advocacy. Some participants also concluded that seeking a second opinion could have helped prevent the DE occurrence.
System Influences (Theme 3)Although participants primarily focused on clinician and patient factors, they also noted worrisome observations about the health care system and physical environment. The most prominent issue addressed was insurance coverage challenges, which hindered some patients’ ability to choose a specific provider or affected accessibility to certain treatment options. Participants also addressed concerns about scheduling challenges and outdated or inappropriate clinic equipment.
Fault Attribution (Theme 4)Participants were asked to determine the individual they believed is primarily at fault for the occurrence of the DE. The majority of patients attributed fault to the dentist who made original DE, although some believed that the DE was a “no-fault” occurrence. It was less common for participants to fault their personal role as the patient when determining culpability.
DE Prevention (Theme 5)Patients assessed whether they believed the DE experience was preventable. The majority of study participants reported that their DE experience was preventable. Few study participants reported that the DE was unpreventable or that they were uncertain regarding preventability.
Domain 3: Impact of DDFsThe impact of the DDFs on patients was assessed through discussing how the experience affected their daily activities and well-being. These effects were divided into 4 major themes: care-seeking behaviors, financial implications, quality of life, and perceptions (Table 4).
Care-Seeking Behaviors (Theme 1)As a result of the DE experience, many participants made profound changes to their prior dental care-seeking behaviors. Some of the most common behavioral affects reported included a desire to change their primary dentist, practicing more caution when selecting a dentist, and increased self-advocacy. Relatively older study participants were more eager than their younger counterparts (34 years and younger) to improve their oral health literacy. Many patients also reported that the experience improved care-seeking behaviors of family and friends. Although some were more forgiving, patients typically expressed experiencing a loss in trust in the dentist who performed DE, leading to a desire to change primary dentist.
Financial Implications (Theme 2)A majority of study participants shared that the DE led to increased financial stress. Some of the specific financial issues mentioned included insurance coverage challenges, payment for additional dental work, and having to take time off work/decreased productivity. Despite interviewing a financially diverse group of individuals, participants from all income levels expressed experiencing these financial stressors.
Quality of Life (Theme 3)A majority of participants’ activities of daily life were negatively impacted by the DE.
Such activities affected included the ability to eat, rest, communicate, and participate in personal hygiene. Many patients had difficulty eating due to pain and missing teeth. Similarly, many reported trouble sleeping due to intense pain. Some struggled to communicate with others and refrained from smiling because of embarrassment of the visual appearance of their teeth. A majority of participants also faced emotional distress and mental health challenges, including increased anxiety, stress, and depressed mood/depression. Despite traditional gender stereotypes adopted by society, there was an even distribution of reported emotional stressors among male and female individuals.
Perception of Dentists (Theme 4)Patients were more likely to report developing an overall negative perception of dentists after the DE experience. For patients who reported a positive perception of dentists, many times this change in mindset was the result of having a positive experience with a different dentist who helped identify and treat DE. These occurrences restored confidence in patients and led to long-term patient-dentist relationships.
Domain 4: Strategies to Reduce DDFsParticipants shared their perspective on efforts to mitigate the occurrence of future DE experiences, and offered several strategies for dentists and patients moving forward. The 3 themes used to describe these initiatives included community awareness and reporting, advice for patients, and advice for dentists (Table 5).
Community Awareness and Reporting (Theme 1)A majority of patients shared the story of their DE experience with community members, family, and friends, as they believed that spreading awareness could help prevent others from experiencing a DE. About two-thirds of patients had a desire to report their DE experience. Those who did not have such desire generally demonstrated a forgiving attitude toward the provider responsible for DE. However, most patients who had a desire to report simply wanted the provider to take accountability and gain awareness to prevent future DE occurrences. Participants shared that the most appropriate avenues for reporting included speaking directly with dental office, informing the state dental boards, or utilization of an online platform. Participants who preferred online reporting admired its accessibility and nonconfrontational approach. Although less common, some participants requested the error be documented in their medical records and some went as far as to mention the possibility of a formal malpractice lawsuit.
Advice for Patients (Theme 2)The most common advice participants provided for patients included practicing self-advocacy, relying on provider reviews when seeking care, and improving oral health literacy. Some patients discussed how enhancing oral health literacy can help improve self-advocacy. Participants also recommended patients practice caution by not hesitating to seek out second opinions and verifying dentists’ credentials.
Advice for Dentists (Theme 3)The most common advice participants provided for dentists included practicing good chairside manner, providing detailed diagnostic workups, and upholding ethical, evidence-based practices. Some participants described dental visits as anxiety-inducing experiences; these individuals wanted to find a dentist that could help put their nerves at ease. Many who believed that they did not receive a detailed workup fault the dentist for lack of time spent evaluating their concerns and caring for too many patients at once. Participants also mentioned that it is important for dentists to demonstrate self-awareness of limitations and to know when to refer out.
DISCUSSIONOur study provides an in-depth qualitative analysis describing the impact DDFs have on patient well-being and quality of life. This patient-centered framework has also helped identify potential contributory factors to DDFs and strategies to help mitigate future occurrences. Given that there is no mandated or standardized reporting method for DEs in dentistry, this study offers valuable insight emphasizing the need for more accessible feedback between patients, dentists, and the oral health care system collectively when these unfortunate events occur.
The patient perspective has unveiled the depths of harm one may suffer when a DDF occurs. Participants openly shared how their DE experiences led to prolonged physical and mental health struggles, and financial hardships. Although the U.S. health care system has made great strides in the accessibility of health insurance coverage, adequate dental insurance remains a burdensome concern.16–18 Study participants frequently expressed concerns regarding dental insurance coverage and reduced work productivity relating to their DE experience. Although this study focused primarily on DEs, more than one-third of participants also reported experiencing treatment errors. This correlation between DE and improper treatment has also been observed in various fields of clinical medicine, emphasizing how vulnerable misdiagnosed individuals are to experiencing further harm.19,20
This study also highlights the urgent need for a national dental safety reporting platform that enables provider learning and improvement, independent from the threat of punishment and litigation. There is currently no mandated or universally accepted voluntary DDF reporting system in the United States, limiting our current understanding to available case reports and malpractice claims, which tend to emphasize more egregious errors rather than minor, more frequent DE. Although the Dental Patient Safety Foundation has provided a voluntary patient safety reporting system in the United States that can be accessed by both patients and dentists, it has unfortunately been underutilized, sighting only 15 cases between 2017 and 2022.21 We suggest a collaboration between the American Dental Association and the Dental Patient Safety Foundation, to increase awareness among dentists and patients about the availability of this reporting system. There needs to be a nationwide campaign for dental patient safety so that it will become commonplace and no longer shrouded in secrecy. Every dental office needs to be encouraged to participate in reporting their near misses and adverse event experiences so that we can all learn from them. Dental conferences all need to have patient safety sections or groups that ensure that these topics make it to the conference agenda.
There was a consensus among study participants for the use of an online platform allowing patients to express concerns in a nonconfrontational manner, so providers can gain awareness and learn from mistakes. Moving forward, perhaps we can look to other countries who have successfully implemented voluntary reporting platforms for DE. Over the last 20 years, Britain’s National Reporting and Learning System has been a forefront leader in establishing one of the largest and most comprehensive national error reporting systems in the world.22 Both providers and patients can submit their concerns via the online platform, which has enabled learning and actionable change from the several million reports they have received.23 However, the National Reporting and Learning System still faces challenges when it comes to reporting dental errors, as dental surgery and orthodontics are some of their lowest reporting specialties.24
U.S. dentistry could also look internally for solutions, as their counterparts in medicine have multiple commonly used methods for addressing errors and improving health care outcomes. U.S. medical hospitals have a mandatory reporting system in place, which cover specific errors and adverse events that could lead to patient harm; however, there is variation in this process governed by state law.25,26 Academic medicine also benefits from the common practice of mortality and morbidity conferences, which are typically a part of grand round presentations. These patient case presentations of unfortunate events are designed to openly discuss harmful error that has occurred and strategize how to achieve quality improvement and error reduction.27 Implementing similar practices in dentistry could help revolutionize patient safety, creating an environment conducive for provider learning.
This study also faced some limitations. Most notably, information gathered relied on the knowledge, honesty, and transparency of the patient population. The stories and perspectives collected in this study were not verified by electronic medical records of incidents, nor did we seek to verify from the provider perspective. However, surveying the providers’ opinions as well could have potentially introduced additional bias to results, given that some may feel the need to defend the standard of care they provided. There was also great variation in health literacy observed among participants that was not quantified, making some interviews more challenging to navigate. Although we did not assess health literacy in this study, interviews were carefully examined, and questionable patient narratives were eliminated from the participant pool. Although robust recruitment efforts were made, the final number of qualified participant interviews was 55 in total. Although this made it challenging to draw strong conclusions about various patient groups and demographics, it also allowed the opportunity to spend substantial time discussing DE scenarios with all participants and providing in-depth analysis of the trends observed. Future studies should aim to continue assessing patient feedback, as the patient perspective is currently an underassessed and undervalued, yet vital component to understanding DEs and progressing the patient safety movement.
CONCLUSIONSDental patients provide valuable insight regarding the many effects of DDFs and are a crucial component in developing strategies to help reduce occurrences of future DDF events. Patients have endured disease progression, prolonged suffering, financial hardships, emotional distress, and many other unfortunate ramifications as the result of potentially preventable DEs. The results of this study highlight the crucial need to create a widely accessible reporting system that not only empowers patients to share these experiences, but also encourages clinician learning in a constructive manner, free of retribution.
ACKNOWLEDGMENTSThe authors would like to thank Dr Elsbeth Kalenderian, who offered initial advice and guidance during the proposal phase of the project. The University of California San Francisco participant recruitment program who provided consultation for designing the Facebook Ads, deployment, and monitoring of participant responses.
REFERENCES 1. Shafer G, Gautham KS. Diagnostic Error. Crit Care Clin. 2022;38:1–10. 2. The National Academies of Sciences, Engineering, and Medicine, Committee on Diagnostic Error in Health Care; Board on Health Care Services; Balogh EP, Miller BT, Ball JR, eds. Improving Diagnosis in Health Care. Washington, DC: National Academies Press (US); 2015. doi: 10.17226/21794. 3. Leape LL, Berwick DM, Bates DW. Counting deaths due to medical errors—reply. JAMA. 2002;288:2405. 4. Saber Tehrani AS, Lee H, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf. 2013;2
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