Everyone—even the most experienced clinician—overlooks symptoms or makes an error at some point in their career that leads to a misdiagnosis. Wound healing is a complex process that uses specific cellular and biochemical actions to achieve wound closure. These processes (homeostasis, inflammation, proliferation, and maturation) occur over defined periods of time. They are often taken for granted as the wound innately granulates, contracts, and epithelializes under optimal conditions. Often, these misdiagnoses are caught either by the same clinician or someone else on the team, but sometimes, they are missed.
Over the past few years, the industry has recognized that misdiagnosis in the U.S. is a critical issue. The healthcare journal STAT reports it leads to an estimated 371,000 deaths and 424,000 permanent disabilities annually at an annual cost of more than $100 billion. Johns Hopkins Medicine notes that this amounts to 795,000 people each year.
For wound care physicians and nurses, recognizing the nuances and complexities of wound diagnosis, better understanding the underlying causes, and developing strategies to enhance diagnostic accuracy can make a big difference in reducing misdiagnosis.
But First: Definitions
Let’s start by making sure we’re all working with the same definition. Clinically, there is a difference between mistake, medical error, and misdiagnosis.
Clinicians and academics usually define a mistake as a broader category of incorrect actions or decisions. The National Academy of Medicine defines errors as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” Misdiagnosis, our focus here, is a diagnostic error where a diagnosis is missed, incorrect, or delayed, as detected by some subsequent definitive test or finding.
How Common is the Misdiagnosis of Wounds?
For many reasons, from an overburdened workforce to a lack of education, misdiagnosis of wounds is not uncommon. Recent studies have shown that a considerable percentage of wounds are initially misdiagnosed. For instance, a study of Medicare beneficiaries in Medical Economics found that up to 20% of chronic wounds are misdiagnosed at the first evaluation, leading to plans developed to treat a different problem than the patient actually faces, which then delay healing and increase morbidity.
Misdiagnosis also leads to increased healthcare costs due to treatments provided for the incorrect injury and extended hospital stays. The worst potential outcome happens when misdiagnosed wounds escalate into more severe conditions, potentially resulting in infection, amputation, and even mortality in extreme cases. What’s the cost? A JAMA Dermatology study has some sobering statistics. Misdiagnosing common wounds, such as cellulitis, which are often caused by or can lead to an infected wound, results in an estimated 50,000 to 130,000 unnecessary hospitalizations annually, costing between $195 million and $515 million. These numbers only address the misdiagnosis of common wounds—these numbers only go up when accounting for all types of wounds.
What are the Commonly Misdiagnosed Wounds?
Common types of misdiagnosed wounds include pressure ulcers and moisture-associated skin damage (MASD). These often present similarly but require different management approaches. Pressure injuries result from sustained pressure, particularly over bony prominences, like the hips and shoulders, while MASD is caused by prolonged exposure to urine, feces or other sources of moisture. Misdiagnosing MASD as a pressure ulcer can lead to ineffective treatment plans that fail to address the underlying cause.
Another frequent misdiagnosis occurs between venous ulcers and arterial ulcers. Differentiating between these two is crucial as they have distinct etiologies and treatment protocols. Venous ulcers typically occur due to chronic venous insufficiency and are often found on the lower legs. In contrast, arterial ulcers result from peripheral artery disease and are usually on the feet or toes. Misdiagnosing a venous ulcer as an arterial ulcer can lead to inappropriate use of compression therapy, exacerbating the condition.
Diabetic foot ulcers and pressure ulcers may appear similar but arise from different conditions. Diabetic foot ulcers are often due to neuropathy and poor circulation, while pressure ulcers result from prolonged pressure. Accurate diagnosis is vital to implementing effective treatment strategies, such as offloading devices for diabetic ulcers or pressure relief for pressure ulcers.
Malignant wounds can be mistaken for chronic wounds due to their similar appearance. However, malignant wounds result from cancerous growth and require oncological interventions. Early identification of malignant wounds is essential for appropriate referrals and treatment plans.
Why Does Misdiagnosis of Wounds Occur?
Several factors contribute to the misdiagnosis of wounds. One primary factor is the need for a comprehensive patient history. Understanding a patient’s medical history is crucial for accurate wound diagnosis. A thorough history can reveal underlying conditions, such as diabetes or peripheral artery disease, that influence wound etiology. Incomplete histories can lead to misdiagnoses and inappropriate treatment plans.
Inadequate training and education also play a significant role in misdiagnoses. Despite advancements in wound care education, there still needs to be more training related to the differential diagnosis of wounds, and it needs to be ongoing. Continuous education and training programs are essential to equip healthcare professionals with the skills to diagnose various wound types accurately.
Overreliance on visual assessment is another common issue, according to wound care expert and Net Health’s Cathy Thomas Hess, BSN, RN, CWCN, vice president and chief clinical officer of Net Health Wound Care. “Clinicians commonly evaluate and manage the typical chronic wounds, such as pressure, vascular, and diabetic ulcers, However, many unusual wounds mimic these common chronic wounds. Because these wounds are often incorrectly assessed, they can be easily misdiagnosed.”
Cathy goes on to note that monitoring the patient closely is critical in verifying diagnosis and correcting for misdiagnosis when it occurs. “Laboratory values can be used to evaluate, manage, and monitor chronic underlying medical conditions and to determine the patient’s nutrition status. […] If healing has not occurred as expected, certain laboratory values can be monitored to ensure that local and systemic factors are not contributing to poor healing.”
What Do Case Studies Reveal About Misdiagnosis of Wounds?
Hypothetical, yet easily relatable case studies highlight the diagnostic challenges in wound care.
- A 75-year-old patient with limited mobility presented with a wound on the sacral region. Initially diagnosed as a pressure ulcer, the wound did not respond to standard treatments. Further assessment revealed that the wound was a case of MASD caused by incontinence. Adjusting the treatment plan to include moisture management strategies led to significant improvement.
- A 60-year-old patient with a history of smoking and diabetes presented with a non-healing wound on the lower leg. The wound care provider initially diagnosed the wound as a venous ulcer and initiated compression therapy. However, the condition worsened, prompting further evaluation. Doppler ultrasound revealed significant arterial insufficiency, and the diagnosis was revised to an arterial ulcer. Appropriate vascular interventions were then implemented, leading to wound healing.
- Another common scenario involves a 50-year-old patient with a persistent wound on the forearm, treated for a chronic wound for several months without improvement. A biopsy was eventually performed, revealing squamous cell carcinoma. Early identification and referral for oncological treatment could have prevented the prolonged period of ineffective wound management.
How Can Diagnostic Accuracy Be Improved?
With so much riding on assessment, combined with the demands of wound care today, it’s no wonder wound care providers are committed to enhancing diagnostic accuracy and comprehensive assessment protocols. There are vital steps to consider, including patient history, physical examination, and diagnostic testing, all of which can significantly reduce misdiagnosis. Standardized protocols ensure consistency and thoroughness in wound evaluations.
A multidisciplinary approach involving wound care specialists, dermatologists, vascular surgeons, and infectious disease experts can also enhance diagnostic accuracy. Cathy points to several tools practitioners can use to improve diagnosis, including:
- Medical records
- Bacterial swab cultures
- Skin biopsies
- Vascular studies
- Nutrition risk assessment
Clinicians like Cathy often make use of many beneficial tools and solutions to make sense of the wounds they’re assessing. New wound imaging solutions make use of mobile imaging and AI to compare images of wounds to a large database in order to more accurately diagnose and treat wounds. Technologies like this help clinicians improve wound measurement accuracy, ensure less variability, and gain real-time insights and wound analysis.
Educating patients about their wound conditions and involving them in the care process can also enhance diagnostic accuracy. Patients and caregivers can provide valuable insights into their symptoms and history, aiding in accurately identifying wound types. Encouraging patient participation also fosters better adherence to treatment plans.
Working Together to Reduce Misdiagnosis
The misdiagnosis of wounds remain an issue the wound care industry strives to address every day as it affects patient outcomes and drives up healthcare costs. To tackle this issue, clinicians need to recognize common diagnostic mistakes and adopt strategies to improve accuracy. Here’s a summary of how our industry can better tackle this problem.
- Comprehensive assessment protocols: Thorough assessments are crucial. Look beyond the surface and gather a complete patient history, understand the wound’s characteristics, and consider underlying health issues.
- Multidisciplinary collaboration: Working together with a team of specialists—like dermatologists, infectious disease experts, and vascular surgeons—can provide a more complete picture and lead to better diagnosis.
- Advanced diagnostic tools: Utilize the latest technology, like laboratory results, mobile solutions, biopsy techniques, and molecular diagnostics, can offer insights that aren’t visible to the naked eye and provide vital insights and analysis to help clinicians make more accurate diagnoses.
- Continuous education: Keep learning, stay updated on the latest research, attend workshops, and participate in training programs to sharpen diagnostic skills.
By focusing on these critical areas, the wound care community can reduce misdiagnoses, improve patient outcomes, and use healthcare resources more efficiently.
