Missed diagnosis and medication error have been highlighted as areas to be prioritised when developing educational strategies and risk management systems for healthcare practitioners in primary care. The findings are the result of systematic review of international malpractice claims in primary care carried out at the HRB Centre for Primary Care Research based at the Royal College of Surgeons in Ireland (RCSI) and published today in the BMJ Open.

Missed diagnosis was the most common source of malpractice claims, accounting for one in four (26%) to two in three (63%) of the total. Among adults, cancer and heart attacks were the most commonly missed diagnosis. Among children, malpractice claims related to meningitis and cancer according to the claims. The second most common reason for claims came from errors in prescribing medication.

Commenting on the review lead author Dr Emma Wallace, a GP and HRB Research Fellow at the Centre, said, "This systematic review is timely considering the increased interest in focusing on primary care as a way of improving patient care and safety. It identifies missed diagnosis and medication error as areas to be prioritised in the development of clinical risk management systems and educational strategies for both undergraduate and postgraduate GP training.

"We recognise that malpractice claims are not a perfect substitute for adverse events, as claims often represent a complex interplay of patient, doctor and societal factors. And not all claims are brought as a result of medical negligence. However, notwithstanding this, malpractice claims do have potential to offer insights into the types and causes of adverse events in clinical practice."

Dr Wallace continued, "The review looked at different aspects such as the prevalence of malpractice claims in primary care; malpractice claims for primary care compared with other specialities; the medical misadventures cited in malpractice claims; and malpractice claims outcomes and compensation awarded."

Key findings from the review include:

• Failure to or delay in diagnosis was the commonest medical misadventure cited in primary care malpractice claims.
• The diagnoses most frequently cited in claims were cancer and myocardial infarction for adults and meningitis for children. The second commonest reason for claims was medication error.
• In the USA, the annual prevalence of malpractice claims against family practitioners appears to have remained relatively stable over the past two decades.
• In the UK and Australia, malpractice claims against GP's appear to be rising.
• Family practice is consistently ranked in the top five most sued specialities on US medical indemnity databases.
• The majority of claims are successfully defended. (Two-thirds of US claims and up to half of UK claims)
• Cognitive process such as reasoning and anchoring biases play a role in misdiagnosis events and medical schools and continuing professional development programmes need to educate practitioners on understanding the nature and psychology of diagnostic error.