36 Misdiagnoses in the context of suspected pandemic influenza or COVID-19: A systematic review

Abstract There have been numerous reports of patients initially misdiagnosed in the H1N1 and COVID-19 pandemics within the literature. A systematic review was undertaken to collate misdiagnoses during the H1N1/2009 and COVID-19 pandemics and identify which cognitive biases may contribute to this. MEDLINE, Embase, Cochrane and MedRxiv databases were searched for misdiagnoses or cognitive biases resulting in misdiagnosis, occurring during the H1N1/2009 or COVID-19 virus pandemics. Eligible studies were quality assessed using JBI criteria; primary outcome was final diagnosis. Sixty-nine studies involving 2551 participants were included. We identified 686 cases of misdiagnosis, categorised as viral respiratory infection, bacterial respiratory infection, non-respiratory infection, and non-infective. Misdiagnoses are listed and relevant investigations are offered. No article described prospective assessment of decision-making in the pandemic setting or de-biasing diagnostic thinking. Further research is required to understand why misdiagnoses occur, harm arising, and how clinicians can be assisted in their decision-making in a pandemic context.