Objective: To characterize the kinds of internal documentation inconsistencies a general-domain large language model (LLM) can surface from real-world discharge summaries, and to identify recurring failure modes that limit reliability at scale. Materials and Methods: We applied a two-stage LLM pipeline---open-ended candidate identification (Gemini 2.5 Pro) followed by context-grounded verification (Gemini 2.5 Flash)---to 3,000 randomly sampled MIMIC-IV-Note discharge summaries. A subset of the pipeline output was then reviewed manually by clinical experts. Results: Our pipeline surfaced 3,460 candidate inconsistencies, affecting 69.7% of admissions. Representative examples spanned demographics, allergies, procedures, diagnoses, laboratory, medications, and care-planning domains, with direct implications for clinical reasoning or patient safety. Expert review also revealed recurring failure modes that arise when verification requires temporal reasoning, evolving-diagnosis context, or knowledge of outpatient-prescribing conventions the model does not natively possess. Discussion: Detection is highly context-dependent: many flagged pairs require anchoring each statement to its source section and clinical domain, then assessing whether the conflict reflects a true contradiction or missing context. We propose a graded ontology spanning strict contradiction and ambiguity, with a schema characterizing each flagged case by category, section, domain, and inconsistency axis. Conclusion: This formative study establishes a methodological foundation and conceptual framework to guide subsequent validated, large-scale EHR-inconsistency analysis.
Large language models are increasingly used for structured extraction from clinical free-text notes, but the sensitivity of their output to upstream configuration choices is less understood than their accuracy on fixed benchmarks. This work measures that sensitivity without human-annotated ground truth, by holding the extraction task fixed and varying one choice at a time. The fixed schema comprises 17 clinical documentation flags on a three-way yes/no/not_documented value set and a 47-tag vocabulary for the primary admission reason. Three prompt variants expressing this schema were each run at two model sizes on MIMIC-IV v3.1 discharge summaries. Cross-prompt agreement was measured by Cohen's kappa on ICD-stratified subsets. A paired same-note comparison isolated the effect of model choice, and a post-hoc collapse of the three-way flags to binary tested the schema's contribution to disagreement. On the three-way flags, the two models reach the same pooled cross-prompt agreement (median kappa 0.69 and 0.68); the larger model raises agreement on some fields and lowers it on others, a redistribution rather than the absence of an effect. Collapsing the schema to binary dissolves most of the cross-prompt disagreement, locating it on the absence-versus-silence distinction rather than on whether the finding is present. On the multi-class admission categorization, changing the model reassigns the dominant tag on close to half of all notes while changing the prompt phrasing reassigns it on roughly one in eight, and the larger model places far less mass on residual catch-all categories (44% to 26%). These patterns indicate a schema-imposed source of disagreement concentrated on the absence-versus-silence axis and a dominance of model over prompt phrasing on multi-class categorization, identified by a reusable methodology for auditing extraction reproducibility on a population-scale deployment.
Discharge summaries require extracting critical information from lengthy electronic health records (EHRs), a process that is labor-intensive when performed manually. Large language models (LLMs) can improve generation efficiency; however, they are prone to producing faithfulness hallucinations, statements that contradict source records, posing direct risks to patient safety. To address this, we present CuraView, a multi-agent framework for sentence-level detection and evidence-grounded explanation of faithfulness hallucinations in discharge summaries. CuraView constructs a GraphRAG-based knowledge graph from patient-level EHRs and implements a closed-loop generation-detection pipeline with sentence-level evidence retrieval and classification spanning four evidence grades from strong support to direct contradiction (E1-E4), yielding structured and interpretable evidence chains. We evaluate CuraView on a subset of 250 patients from the Discharge-Me benchmark, with 50 patients held out for testing. Our fine-tuned Qwen3-14B detection model achieves an F1 of 0.831 on the safety-critical E4 metric (90.9% recall, 76.5% precision) and an F1 of 0.823 on E3+E4, representing a 50.0% relative improvement over the base model and outperforming RAGTruth-style and QAGS-style baselines. These results demonstrate that evidence-chain-based graph retrieval verification substantially improves the factual reliability of clinical documentation, while simultaneously producing reusable annotated datasets for downstream model training and distillation.
Large language models are increasingly deployed in agentic pipelines that depend on the model evaluating its own outputs without external verification. The reliability of these pipelines depends on an implicit assumption: that the model applies relevant concepts the same way when it generates an output and later evaluates that output. We propose a new measure, generator-evaluator self-consistency, to test this assumption directly and apply it to 10 frontier models across 491 concepts. We find, first, that there is substantial variation in self-consistency. Second, we find that in a clinical setting with physician-validated mistakes (Proniakin et al., 2025), across models, those with higher self-consistency are linked to greater vulnerability to mistakes. Thus, even when models consistently apply concepts they may not be safe to deploy. This is evidence of a consistency dilemma in LLMs: self-consistency is operationally useful, but models that are more consistent are also more prone to mistakes.