Skip to main content
Subscribed

Diagnostic Safety

Last Updated: October 12, 2022
Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team

Description
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Library Organization
Custom - This library is organized by custom section header names.
Foundations (4)

Thousands of patients die every year due to diagnostic errors. While clinicians’ cognitive biases play a role in many diagnostic errors, underlying health care system problems also contribute to missed and delayed diagnoses.

Singh H, ed. BMJ Qual Saf. 2013;22(suppl 2):ii1-ii72.

Articles in this special issue cover efforts to reduce diagnostic errors, including patient engagement and cognitive debiasing.

Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISBN: 9780309377690.

The National Academy of Medicine (formerly the Institute of Medicine) launched the patient safety movement with the publication of its report To Err Is Human. The group has now released a report about diagnosis, which they describe as a blind spot in... Read More

Rockville, MD: Agency for Healthcare Research and Quality; 2020-2022.

Diagnostic safety has increased its footprint in research, publication, and awareness efforts worldwide. This series of occasional publications introduces diagnostic process concerns and efforts to address them. Topics covered include clinical... Read More

View More View Less
View More View Less
Sacco AY, Self QR, Worswick EL, et al. J Patient Saf. 2021;17:e1759-e1773.

Using the IOM definition of diagnostic error, this study interviewed hospitalized adults to characterize their experiences with diagnostic errors and their perspectives on causes, impacts and prevention strategies. Nearly 40% of patients interviewed... Read More

Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No. 21-0047-2-EF.

Patient and family engagement is core to effective and safe diagnosis. This new toolkit from the Agency for Healthcare Research and Quality promotes two strategies to promote meaningful engagement and communication with patients to improve diagnostic... Read More

View More View Less
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018.

Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal test result management systems is essential for closing the loop so that results can be acted upon in a timely manner. The Partnership for Health... Read More

View More View Less
Graber ML, Rusz D, Jones ML, et al. Diagnosis (Berl). 2017;4:225-238.

Teamwork has been highlighted as a key component of patient safety that also applies to improving diagnosis. This commentary describes how the team approach to diagnosis is anchored in patient-centered care and suggests that the diagnostic team must... Read More

Kahneman D, Slovic P, Tversky A, eds. Cambridge, NY: Cambridge University Press; 1982. ISBN: 0521284147.

Judgement is an inherently human activity that is susceptible to a variety of influences that degrade its effectiveness. This assembled volume collectively helped to establish an understanding of the mechanisms by which humans commit cognitive errors... Read More

View More View Less

JAMA. Nov 2021-Sep 2022. 

Diagnostic excellence achievement is becoming a primary focus in health care. This 20 article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges, and priorities for improvement across the system.... Read More

All Library Content (31)
Search Icon

Washington, DC: Leapfrog Group; July 2022.

Diagnostic safety is beginning to be established as a systemic, rather than solely an individual performance issue. This report recommends strategies that support systemic work toward diagnostic excellence and selected implementation stories that illustrate success. It is a part of a larger initiative devoted to the improvement of organizational and team activities in tandem with clinical processes to minimize the impact of human error on diagnosis.

Rockville, MD: Agency for Healthcare Research and Quality; July 2022.  AHRQ Publication No. 22-0038.

Diagnostic improvement continues to gain focus as a goal in health care. The Measure Dx tool provides teams with guidance and strategies to detect and learn from diagnostic errors in their organizations. It includes a checklist to gauge readiness for implementation, measurement strategies, and recommendations for analyzing data and translating findings into front line care. 
Special or Theme Issue

JAMA. Nov 2021-Sep 2022. 

Diagnostic excellence achievement is becoming a primary focus in health care. This 20 article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges, and priorities for improvement across the system. 
Dave N, Bui S, Morgan C, et al. BMJ Qual Saf. 2022;31:297-307.
This systematic review provides an update to McDonald et al’s 2013 review of strategies to reduce diagnostic error.  Technique (e.g., changes in equipment) and technology-based (e.g. trigger tools) interventions were the most studied intervention types. Future research on educational and personnel changes would be useful to determine the value of these types of interventions.

Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No. 21-0047-2-EF.

Patient and family engagement is core to effective and safe diagnosis. This new toolkit from the Agency for Healthcare Research and Quality promotes two strategies to promote meaningful engagement and communication with patients to improve diagnostic safety: (1) a patient note sheet to help patients share their story and symptoms and (2) orientation steps to support clinicians listening and “presence” during care encounters.
Giardina TD, Korukonda S, Shahid U, et al. BMJ Qual Saf. 2021;30:996-1001.
Patient complaints are increasingly used to identify opportunities for patient safety improvement and to predict avoidable patient harm. In this retrospective study, researchers analyzed patient complaint and medical record data and found that manual reviews by clinicians can identify patterns of failures in the diagnostic process. Qualitative analysis of complaints revealed three themes associated with diagnostic error – reports of return visits for the same or worsening symptoms, interpersonal issues, and diagnostic testing issues.
Special or Theme Issue

Rockville, MD: Agency for Healthcare Research and Quality; 2020-2022.

Diagnostic safety has increased its footprint in research, publication, and awareness efforts worldwide. This series of occasional publications introduces diagnostic process concerns and efforts to address them. Topics covered include clinical reasoning, decision making, and patient engagement.
Wright B, Lennox A, Graber ML, et al. BMC Health Serv Res. 2020;20:897.
Incomplete or delayed test result communication can contribute to diagnostic errors, delayed treatments and patient harm. The authors synthesized systematic and narrative reviews from multiple perspectives discussing diagnostic test result communication failures. The review identified several avenues for improving closed-loop communication through the use of technology, audit and feedback, and use of point-of-care or bedside testing.

Washington DC; National Quality Forum: October 6, 2020.

With input from a stakeholder committee, the National Quality Forum identified recommendations for the practical application of the Diagnostic Process and Outcomes domain of the 2017 Measurement Framework  for measuring and improving diagnostic error and patient safety. The committee developed four ‘use cases’ (missed subtle clinical findings; communication failures; information overload; and dismissed patients) reflecting high priority examples of diagnostic error that can result in patient harm. The report includes comprehensive, broad-scope, actionable, and specific recommendations for implementing quality improvement activities to engage patients, educate clinicians, leverage technology, and support a culture of safety with the goal of reducing diagnostic errors. 
Thomas J, Dahm MR, Li J, et al. J Am Med Inform Assoc. 2020;27:1214–1224.
This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern. Thematic analyses identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.  
Sacco AY, Self QR, Worswick EL, et al. J Patient Saf. 2021;17:e1759-e1773.
Using the IOM definition of diagnostic error, this study interviewed hospitalized adults to characterize their experiences with diagnostic errors and their perspectives on causes, impacts and prevention strategies. Nearly 40% of patients interviewed reported at least one diagnostic error in the past 5 years that adversely impacted their emotional and physical well-being. Qualitative analysis revealed five main themes underlying the causes of diagnostic error: problems with clinical evaluation, limited time with clinicians, poor communication between clinicians and patients or between clinicians, and systems failures. Suggested strategies to reduce diagnostic error included improvements to clinical management, increase patient access to clinicians, communication improvements between patients and clinicians and between clinicians, and self-advocacy by patients.
Gartland RM, Myers LC, Iorgulescu JB, et al. J Patient Saf. 2020;17:576-582.
This study reviewed medical malpractice claims spanning a 10-year period involving deaths related to inpatient care. Two physicians completed a blinded review of the claim to determine whether there was major, minor or no discordance between the final clinical diagnoses and the pathological diagnoses ascertained at autopsy. The researchers found that 31% of claims demonstrated major discordance between autopsy and clinical findings. The most common diagnoses newly discovered on autopsy were infection or sepsis, pulmonary or air embolus, and coronary atherosclerosis. In addition, the researchers found that performing an autopsy was not associated with either the likelihood of payout on a malpractice or the median size of that payout. They conclude that physicians should not hesitate to advocate for autopsies to investigate unexpected in-hospital deaths.
Meyer AND, Giardina TD, Spitzmueller C, et al. J Med Internet Res. 2019;22:e14679.
Online symptoms checkers are increasingly used, but formal validation of these tools is lacking. This survey of 329 patients’ experience using an artificial intelligence-assisted online symptom checker found that patients most commonly used the tool to understand the causes of their symptoms (76.3%), determining whether (33.2%) or where (20.7%) to seek care. Patients who had previously experienced a diagnostic error were more likely to use the tool to determine where they should seek care than patients who had not previously experienced diagnostic error.
Giardina TD, Haskell H, Menon S, et al. Health Aff (Millwood). 2018;37:1821-1827.
Reducing harm related to diagnostic error remains a major focus within patient safety. While significant effort has been made to engage patients in safety, such as encouraging them to report adverse events and errors, little is known about patient and family experiences related specifically to diagnostic error. Investigators examined adverse event reports from patients and families over a 6-year period and found 184 descriptions of diagnostic error. Contributing factors identified included several manifestations of unprofessional behavior on the part of providers, e.g., inadequate communication and a lack of respect toward patients. The authors suggest that incorporating the patient voice can enhance knowledge regarding why diagnostic errors occur and inform targeted interventions for improvement. An Annual Perspective discussed ongoing challenges associated with diagnostic error. The Moore Foundation provides free access to this article.
Murphy DR, Meyer AN, Sittig DF, et al. BMJ Qual Saf. 2019;28:151-159.
Identifying and measuring diagnostic error remains an ongoing challenge. Trigger tools are frequently used in health care to detect adverse events. Researchers describe the Safer Dx Trigger Tools Framework as it applies to the development and implementation of electronic trigger tools that use electronic health record data to detect and measure diagnostic error. The authors suggest that by identifying possible diagnostic errors, these tools will help elucidate contributing factors and opportunities for improvement. They also suggest that, if used prospectively, such tools might enable clinicians to take preventive action. However, to design and implement these electronic trigger tools successfully, health systems will need to invest in the appropriate staff and resources. A past PSNet perspective discussed ongoing challenges associated with diagnostic error.

Kahneman D, Slovic P, Tversky A, eds. Cambridge, NY: Cambridge University Press; 1982. ISBN: 0521284147.

Judgement is an inherently human activity that is susceptible to a variety of influences that degrade its effectiveness. This assembled volume collectively helped to establish an understanding of the mechanisms by which humans commit cognitive errors. Chapters examine how biases and heuristics affect judgement. Availability and representativeness biases are of particular focus. The editors also include content on how to understand the effects of bias and adjust to prevent their negative influence.
Thousands of patients die every year due to diagnostic errors. While clinicians’ cognitive biases play a role in many diagnostic errors, underlying health care system problems also contribute to missed and delayed diagnoses.
Millenson ML, Baldwin JL, Zipperer L, et al. Diagnosis (Berl). 2018;5:95-105.
Recently, several mobile health care applications have been developed and marketed directly to nonclinician consumers. Researchers reviewed the literature regarding direct-to-consumer diagnostic applications. They found wide variation in the safety of these applications and suggest that further research is needed to thoroughly assess their effectiveness.