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.
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
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
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
This commentary describes a three-element framework to enable study and evaluation of diagnostic errors. The model considers the sociotechnical process... Read More
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... Read More
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... 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... Read More
This commentary explores diagnosis of common conditions in primary care and highlights approaches for studying the process, such as practice variation and... 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... Read More
Patient complaints are increasingly used to identify opportunities for patient safety improvement and to predict avoidable patient harm. In this... 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... 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... Read More
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... Read More
Recently, several mobile health care applications have been developed and marketed directly to nonclinician consumers. Researchers reviewed the literature regarding direct... 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... Read More
Identifying and measuring diagnostic error remains an ongoing challenge. Trigger tools are frequently used in health care to detect adverse events.... Read More
Online symptoms checkers are increasingly used, but formal validation of these tools is lacking. This survey of 329 patients’... Read More
This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern.... Read More
Incomplete or delayed test result communication can contribute to diagnostic errors, delayed treatments and patient harm.... Read More
In light of recent expert analysis and improvement work, the concept of treating diagnosis as team activity is gaining acceptance. This... 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... Read More
Diagnostic error reduction continues to be a patient safety focus. This article outlines innovative ways clinical laboratory professionals can support diagnostic... 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... 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... Read More
The author discusses how heuristics can lead to errors in physician judgement and decision making.
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... Read More
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... Read More
Singh H, ed. BMJ Qual Saf. 2013;22(suppl 2):ii1-ii72.