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Diagnostic Safety Improvement

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    • Last Updated: July 23, 2024
    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 (5)
    Classic
    Improving Diagnosis in Health Care.
    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,... Read More

    Diagnostic Safety Issue Briefs.

    Rockville, MD: Agency for Healthcare Research and Quality; 2020-2024.

    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... Read More

    Diagnostic Excellence.

    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 uncertainties, and... Read More

    Diagnostic Error in Medicine.

    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.

    View More View Less
    Assessing diagnostic performance.
    Cosby K, Yang D, Fineberg HV. NEJM Evid. 2024;3:EVIDra2300232.

    Assessing diagnostic performance to reduce diagnostic errors requires a shared understanding of the diagnostic purpose. This article describes the various ways evidence is collected based on the diagnostic purpose:... Read More

    Toolkit for Engaging Patients to Improve Diagnostic Safety.

    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... Read More

    View More View Less
    View More View Less
    The new diagnostic team.
    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... Read More

    All Library Content (24)
    Search Icon
    Toolkit
    Patient and Family Advisory Council (PFAC) Toolkit for Exploring Diagnostic Quality.
    Alpharetta, GA: Society to Improve Diagnosis in Medicine; February 2024.
    Patient and Family Advisory Councils (PFACs) can help to operationalize patient engagement in healthcare safety improvement work. This toolkit targets diagnostic excellence and educating PFAC members on the diagnostic process to enable their rich involvement in improvement work. The kit features videos, sections on the role of PFACs in diagnostic improvement, selected readings, letter templates and a glossary.
    Review
    Assessing diagnostic performance.
    Cosby K, Yang D, Fineberg HV. NEJM Evid. 2024;3(2):EVIDra2300232.
    Assessing diagnostic performance to reduce diagnostic errors requires a shared understanding of the diagnostic purpose. This article describes the various ways evidence is collected based on the diagnostic purpose: optimal clinical care (e.g., usefulness of testing), population screening and disease surveillance, quality improvement, and regulation (e.g., of machine learning). This is the first in a series of articles that will further elaborate on these diagnostic purposes.
    Study
    Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study.
    Bell SK, Amat MJ, Anderson TS, et al. J Am Med Inform Assoc. 2024;31(3):622-630.
    Prompt completion of diagnostic tests or referrals is paramount to receiving a timely diagnosis and treatment. In this study, completion rates for three common diagnostic tests or referrals (i.e., colonoscopy, concerning skin lesions, cardiac stress test) were compared between patients who do not access a patient portal; patients who do have access but do not read visit notes; and patients who have access and who do read visit notes. Completion rates were highest for patients who read visit notes (62%) compared with those who do not read notes (57%) and those with no portal use (54%). The authors state timely completion rates for all groups remain below recommend thresholds and increased patient engagement is required.
    Study
    Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process.
    Choi JJ, Rosen MA, Shapiro MF, et al. Diagnosis (Berl). 2023;10(4):363-374.
    Teamwork is increasingly seen as an important component of diagnostic excellence. Through a systematic review and observations of team dynamics in a hospital medical ward, researchers identified three areas requiring additional research- (1) team structure, (2) contextual factors, and (3) emergent states (e.g., shared mental models).
    Book/Report
    Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors.

    Agency for Healthcare Research and Quality, Rockville, MD. July 2023.

    Engaging patients to capture their insights after diagnostic error is one of the top patient safety strategies. This pair of issue briefs describes how organizations can use patient experience to inform improvements in diagnosis. Volume 1: Why Patient Narratives Matter highlights how patient perspectives offer unique information about the impacts of diagnosis-related events on patient care trajectories through the healthcare system. Volume 2: Eliciting Patient Narratives emphasizes that rigorous methods are needed to elicit patient experiences. Both briefs identify areas in which more research is needed about patients’ diagnostic experience.
    Commentary
    Artificial intelligence in clinical diagnosis: opportunities, challenges, and hype.
    Kulkarni PA, Singh H. JAMA. 2023;330(4):317-318.
    Artificial intelligence (AI) is an emerging technology to potentially improve care timeliness and diagnostic accuracy. This commentary provides a grounded assessment of this potential by examining clinician knowledge, physician examination skills, and health record data factors that affect the effect of AI chatbots as a tool driving diagnostic safety.
    Book/Report
    Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.

    Washington, DC: Leapfrog Group; July 2024.

    Diagnostic safety is beginning to be established as a systemic, rather than solely an individual performance issue. This updated 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.
    Toolkit
    Measure Dx: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events.

    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
    Diagnostic Excellence.

    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 uncertainties, and priorities for improvement across the system. 
    Review
    Interventions targeted at reducing diagnostic error: systematic review.
    Dave N, Bui S, Morgan C, et al. BMJ Qual Saf. 2022;31(4):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.
    Tools/Toolkit
    Toolkit for Engaging Patients to Improve Diagnostic Safety.

    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.
    Study
    Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.
    Giardina TD, Korukonda S, Shahid U, et al. BMJ Qual Saf. 2021;30(12):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
    Diagnostic Safety Issue Briefs.

    Rockville, MD: Agency for Healthcare Research and Quality; 2020-2024.

    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 electronic health records documentation, patient partnership and rural health care.
    Book/Report
    Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. Final Report

    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. 
    Study
    Variation in electronic test results management and its implications for patient safety: a multisite investigation.
    Thomas J, Dahm MR, Li J, et al. J Am Med Inform Assoc. 2020;27(8):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.  
    Study
    Emerging Classic
    Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety.
    Giardina TD, Haskell H, Menon S, et al. Health Aff (Millwood). 2018;37(11):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.
    Review
    Emerging Classic
    Application of electronic trigger tools to identify targets for improving diagnostic safety.
    Murphy DR, Meyer AN, Sittig DF, et al. BMJ Qual Saf. 2019;28(2):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.
    Special or Theme Issue
    Diagnostic Error in Medicine.

    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.
    Commentary
    The new diagnostic team.
    Graber ML, Rusz D, Jones ML, et al. Diagnosis (Berl). 2017;4(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 expand beyond the focus on physicians and involve a wide range of professionals, including pathologists, allied health practitioners, and medical librarians.
    Review
    Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action.
    Gleason KT, Davidson PM, Tanner EK, et al. Diagnosis (Berl). 2017;4(4):201-210.
    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 the diagnostic process to enhance multidisciplinary teamwork and patient involvement. The authors suggest improvements in health care culture is required to implement the recommended changes, which include a focus on creating opportunities for shifting the process to be more patient centered.
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