Diagnostic Safety

This commentary describes a three-element framework to enable study and evaluation of diagnostic errors. The model considers the sociotechnical process through which diagnosis happens, the external... Read More

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... Read More

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... Read More

A systematic review of the literature from 1966 to 2002 was performed to determine the rate at which autopsies detect important, clinically missed diagnoses and the extent to which this rate has changed over time... Read More

This commentary explores diagnosis of common conditions in primary care and highlights approaches for studying the process, such as practice variation and patterning. The authors suggest big data as a method... Read More

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... Read More

This book includes narratives about how physicians and patients work through the challenging and complex task of diagnosis.

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... Read More

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... Read More

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... Read More

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 IT... Read More

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... Read More

In light of recent expert analysis and improvement work, the concept of treating diagnosis as team activity is gaining acceptance. This review describes a framework for engaging nurses in... Read More

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 expand beyond the focus on... Read More

Diagnostic error reduction continues to be a patient safety focus. This article outlines innovative ways clinical laboratory professionals can support diagnostic excellence, such as improved communication between... Read More

Strike 3—You're OUT! Many a baseball game hinges on the accuracy of calls made by the men in black behind home plate. Umpires make crucial split-second decisions under conditions of substantial pressure and uncertainty, a... Read More

This article summarizes a series of cognitive error types referred to as “cognitive dispositions to respond” (CDRs). The author reviews previously described CDRs, such as failures in perception and heuristics,... Read More

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

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... Read More

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. 

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... Read More