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Diagnostic Safety

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    • Last Updated: August 21, 2023
    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)
    Diagnostic Errors

    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.

    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.

    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; 2020-2023.

    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

    Improving Diagnostic Safety and Quality
    Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD |

    Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to... Read More

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    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

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    Health IT Safe Practices for Closing the Loop.
    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... Read More

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    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

    Classic
    Judgment under Uncertainty: Heuristics and Biases.

    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... Read More

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    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 priorities for... Read More

    All Library Content (32)
    Search Icon
    Review
    Emerging Classic
    Beyond Dr. Google: the evidence on consumer-facing digital tools for diagnosis.
    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.
    Toolkit
    Health IT Safe Practices for Closing the Loop.
    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 IT Patient Safety convened a working group to identify how technology can be used to facilitate improved communication and timely action regarding test results. This report summarizes the methods used by the working group and their findings. Recommendations include improving communication by standardizing the format of test results, including required timing for diagnostic testing responses, automating the notification process in electronic health records, and optimizing alerts to reduce alert fatigue. A past WebM&M commentary discussed a case involving ambulatory test result management.
    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;4:225-238.
    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;4:201-210.
    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.
    Commentary
    Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices.
    Rao G, Epner P, Bauer V, et al. Diagnosis (Berl). 2017;4:67-72.
    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 to mine electronic medical records to identify the information needed to inform improvement.
    Book/Report
    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, which they describe as a blind spot in health care. Available evidence suggests that most Americans will experience a missed or delayed diagnosis in their lifetime. The committee made several recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care teams, enhancing patient engagement in the diagnostic process, implementing large-scale error reporting systems with feedback and corrective action, and improving health information technology (as recommended in prior reports). Longer-term recommendations include establishing a work system and safety culture that foster timely and accurate diagnosis, improving the medical liability system to foster learning from missed or delayed diagnoses, reforming the payment system to support better diagnosis, and increasing funding for research in diagnostic safety. The report emphasizes the need for much more effort, and far more resources, at the practice, policy, and research levels to address this pressing safety problem.
    Commentary
    Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.
    Singh H, Sittig DF. BMJ Qual Saf. 2015;24:103-110.
    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 factors that influence the patient–clinician encounter, and the postdiagnosis patient outcomes to define measures.
    Review
    Classic
    Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.
    Shojania KG, Burton EC, McDonald KM, et al. JAMA. 2003;289:2849-2856.
    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. Fifty-three autopsy series were studied that reported diagnoses involving a primary cause of death (major errors) and those likely to have affected patient outcome (class I errors). The median major error rate was 23.5% (4.1% to 49.8%), and the median class I error rate was 9.0%. Over time, there were relative decreases in major errors and class I errors of 19.4% and 33.4% per decade, respectively. Despite these decreases, the authors estimate that for modern U.S. institutions, there is likely a major error rate from 8.4% to 24.4% and a class I error rate from 4.1% to 6.7%.
    Study
    Classic
    The importance of cognitive errors in diagnosis and strategies to minimize them.
    Croskerry P. Acad Med. 2003;78:775-780.
    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, overconfidence bias, and anchoring. He aims to provide a detailed perspective on the cognitive challenges that impact diagnostic decision making, including strategies to handle them. The author concludes that in order to reduce diagnostic errors, further investigation must pursue effective methods of “cognitively debiasing” ourselves when making clinical decisions.
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