Definitions and Measurements for Atypical Presentations at Risk for Diagnostic Errors in Internal Medicine: Protocol for a Scoping Review

Background: Atypical presentations have been increasingly recognized as a significant contributing factor to diagnostic errors in internal medicine. However, research to address associations between atypical presentations and diagnostic errors has not been evaluated due to the lack of widely applicable definitions and criteria for what is considered an atypical presentation. Objective: The aim of the study is to describe how atypical presentations are defined and measured in studies of diagnostic errors in internal medicine and use this new information to develop new criteria to identify atypical presentations at high risk for diagnostic errors. Methods: This study will follow an established framework for conducting scoping reviews. Inclusion criteria are developed according to the participants, concept, and context framework. This review will consider studies that fulfill all of the following criteria: include adult patients (participants); explore the association between atypical presentations and diagnostic errors using any definition, criteria, or measurement to identify atypical presentations and diagnostic errors (concept); and focus on internal medicine (context). Regarding the type of sources, this scoping review will consider quantitative, qualitative, and mixed methods study designs; systematic reviews; and opinion papers for inclusion. Case reports, case series, and conference abstracts will be excluded. The data will be extracted through MEDLINE, Web of Science, CINAHL, Embase, Cochrane Library, and Google Scholar searches. No limits will be applied to language, and papers indexed from database inception to December 31, 2023, will be included. Two independent reviewers (YH and RK) will conduct study selection and data extraction. The data extracted will include specific details about the patient characteristics (eg, age, sex, and disease), the definitions and measuring methods for atypical presentations and diagnostic errors, clinical settings (eg, department and outpatient or inpatient), type of evidence source, and the association between atypical presentations and diagnostic errors relevant to the review question. The extracted data will be presented in tabular format with descriptive statistics, allowing us to identify the key components or types of atypical presentations and develop new criteria to identify atypical presentations for future studies of diagnostic errors. Developing the new criteria will follow guidance for a basic qualitative content analysis with an inductive approach. Results: As of January 2024, a literature search through multiple databases is ongoing. We will complete this study by December Conclusions: This scoping review aims to provide rigorous evidence to develop new criteria to identify atypical presentations at high risk for diagnostic errors in internal medicine. Such criteria could facilitate the development of a comprehensive conceptual model to understand the associations between atypical presentations and diagnostic errors in internal medicine.