Study Diagnostic errors in medicine: a case of neglect. Citation Text: Graber ML. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2005;31(2):106-13. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 6, 2005 Graber ML. Jt Comm J Qual Patient Saf. 2005;31(2):106-13. View more articles from the same authors. PubMed citation Available at Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Graber ML. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2005;31(2):106-13. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) The incidence of diagnostic error in medicine. August 14, 2013 Inpatient notes: just what the doctor ordered—checklists to improve diagnosis. May 1, 2019 Improving diagnosis in health care—the next imperative for patient safety. November 18, 2015 Reducing diagnostic error through medical home-based primary care reform. August 11, 2010 How insight contributes to diagnostic excellence. September 21, 2022 Performance of a web-based clinical diagnosis support system for internists. January 23, 2008 Preventing diagnostic errors in primary care. October 12, 2016 Overconfidence as a cause of diagnostic error in medicine. May 14, 2008 Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events. February 14, 2018 The impact of electronic health records on diagnosis. October 4, 2017 Bringing diagnosis into the quality and safety equations. October 3, 2012 Diagnostic error in internal medicine. July 27, 2005 Measures to improve diagnostic safety in clinical practice. November 2, 2016 Evaluation of outcomes from a national patient-initiated second-opinion program. June 24, 2015 Checklists to reduce diagnostic errors. February 9, 2011 Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives. November 25, 2020 What interventions could reduce diagnostic error in emergency departments? A review of evidence, practice and consumer perspectives. July 24, 2019 When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine. September 11, 2013 The patient is in: patient involvement strategies for diagnostic error mitigation. September 4, 2013 Electronic health record–related events in medical malpractice claims. January 6, 2016 The global burden of diagnostic errors in primary care. August 24, 2016 The critical need for nursing education to address the diagnostic process. February 17, 2021 Learning from tragedy: the Julia Berg story. December 12, 2018 Blink or think: can further reflection improve initial diagnostic impressions? November 19, 2014 A call to action: next steps to advance diagnosis education in the health professions. June 8, 2022 Patient-initiated second opinions: systematic review of characteristics and impact on diagnosis, treatment, and satisfaction. July 15, 2015 The next organizational challenge: finding and addressing diagnostic error. March 5, 2014 Evidence that nurses need to participate in diagnosis: lessons from malpractice claims. April 29, 2020 System-related interventions to reduce diagnostic errors: a narrative review. February 1, 2012 The effects of a mid-day nap on the neurocognitive performance of first-year medical residents: a controlled interventional pilot study. December 19, 2012 Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events. May 25, 2022 Cognitive interventions to reduce diagnostic error: a narrative review. May 16, 2012 Improving diagnosis by improving education: a policy brief on education in healthcare professions. September 12, 2018 Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review. March 14, 2018 Competencies for improving diagnosis: an interprofessional framework for education and training in health care. August 28, 2019 Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. September 1, 2021 The new diagnostic team. November 22, 2017 Checklists to prevent diagnostic errors: a pilot randomized controlled trial. July 8, 2015 Identifying trigger concepts to screen emergency department visits for diagnostic errors. December 16, 2020 Hospital computerized provider order entry adoption and quality: an examination of the United States. January 5, 2011 Assessing the relationship between patient safety culture and EHR strategy. July 20, 2016 Strategies for developing and recognizing faculty working in quality improvement and patient safety. June 1, 2016 Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers. March 16, 2011 Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fentanyl and patient safety. April 26, 2023 Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? August 25, 2021 Clinician factors associated with delayed diagnosis of appendicitis. July 5, 2023 Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments. October 26, 2022 A systems approach to morbidity and mortality conference. July 28, 2010 Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart failure. August 2, 2023 Venous thromboembolism after trauma: a never event? October 10, 2012 Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States. June 22, 2022 Association between hospital performance on patient safety and 30-day mortality and unplanned readmission for Medicare fee-for-service patients with acute myocardial infarction. August 3, 2016 Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans — Los Angeles, California, 2020. June 10, 2020 Managing health IT risks: reflections and recommendations. June 13, 2018 An organisation without a memory: a qualitative study of hospital staff perceptions on reporting and organisational learning for patient safety. November 18, 2015 Patient safety records: silent witness. October 1, 2008 Patient safety and leadership: do you walk the walk? May 3, 2017 Correlates of the third victim phenomenon. April 12, 2017 Improving the quality of health care: what's taking so long? October 23, 2013 A novel tool for organisational learning and its impact on safety culture in a hospital dispensary. June 20, 2012 Eight-year experience with a neurosurgical checklist. August 18, 2010 Patient safety in obstetrics and gynecology: an agenda for the future. November 15, 2006 Organisational reporting and learning systems: innovating inside and outside of the box. March 25, 2015 Shape matters: a neglected feature of medication safety: why regulating the shape of medication containers can improve medication safety. February 22, 2023 Safety cases for digital health innovations: can they work? July 14, 2021 Criminal liability for nursing and medical harm. August 3, 2022 Race and the clinical diagnosis of depression in new primary care patients. October 25, 2011 Time to get off this pig's back?: the human factors aspects of the mismatch between device and real-world knowledge in the health care environment. November 8, 2006 Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. August 15, 2007 Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. July 1, 2020 Opioid medication discontinuation and risk of adverse opioid-related health care events. June 12, 2019 The aging surgeon. September 7, 2016 Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. October 7, 2009 Effects of learning climate and registered nurse staffing on medication errors. January 5, 2011 Nurse staffing and medication errors: cross-sectional or longitudinal relationships? October 29, 2008 Ambiguity and workarounds as contributors to medical error. April 27, 2005 Physician evaluation after medical errors: does having a computer decision aid help or hurt in hindsight? March 1, 2006 The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. February 28, 2007 Burden of difficult encounters in primary care: data from the Minimizing Error, Maximizing Outcomes Study. March 4, 2009 The impact of the COVID-19 pandemic on Emergency Department visits and patient safety in the United States. August 26, 2020 Improving Weekend Out Of Hours Surgical Handover (WOOSH). May 25, 2016 High-reliability health care: getting there from here. October 2, 2013 Current approaches to punitive action for medication errors by boards of pharmacy. May 22, 2013 The role of dynamic trade-offs in creating safety—a qualitative study of handover across care boundaries in emergency care. October 28, 2015 Aiming higher to enhance professionalism: beyond accreditation and certification. May 27, 2015 A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists. August 27, 2014 Optimizing transitions of care to reduce rehospitalizations. July 2, 2014 Elective surgical patients' narratives of hospitalization: the co-construction of safety. March 5, 2014 Antecedents of severe and nonsevere medication errors. April 22, 2009 Injury and death associated with incidents reported to the Patient Safety Net. September 23, 2009 Attending physician work hours: ethical considerations and the last doctor standing. July 29, 2009 Structured communication for patient safety in emergency medical services: a legal case report. May 19, 2010 Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety. March 15, 2023 Eight human factors and ergonomics principles for healthcare artificial intelligence. November 2, 2022 The evolution of the Anesthesia Patient Safety Movement in America: lessons learned and considerations to promote further improvement in patient safety. January 26, 2022 Some unintended effects of teamwork in healthcare. March 10, 2010 The ongoing quality improvement journey: next stop, high reliability. April 20, 2011 Medical liability and patient safety: setting the proper course. May 18, 2005 The wrong patient. March 27, 2005 An investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomes. December 13, 2006 View More Related Resources Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 Measure Dx: implementing pathways to discover and learn from diagnostic errors. September 28, 2022 Annual Perspective Patient Safety in the Ambulatory Care Setting August 5, 2022 Improving medical residents’ self-assessment of their diagnostic accuracy: does feedback help? February 2, 2022 Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. September 1, 2021 Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives. November 25, 2020 A program to provide clinicians with feedback on their diagnostic performance in a learning health system. October 28, 2020 Making Healthcare Safer III. March 18, 2020 WebM&M Cases Think Like a Surgeon September 25, 2019 Communication between primary and secondary care: deficits and danger. August 21, 2019 Recommendations for using the Revised Safer Dx instrument to help measure and improve diagnostic safety. August 21, 2019 Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. July 10, 2019 Gaps in ambulatory patient safety for immunosuppressive specialty medications. June 12, 2019 Classifying safety events related to diagnostic imaging from a safety reporting system using a human factors framework. May 29, 2019 Incidence of multiple sclerosis misdiagnosis in referrals to two academic centers. May 1, 2019 In-hospital sequelae of injurious falls in 24 medical/surgical units in four hospitals in the United States. March 13, 2019 Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery. March 13, 2019 Comparing the outcomes of reporting and trigger tool methods to capture adverse events in the emergency department. February 27, 2019 Perception of patient safety culture in pediatric long-term care settings. February 13, 2019 Predictors of adverse events and medical errors among adult inpatients of psychiatric units of acute care general hospitals. January 30, 2019 Fatal flaws in clinical decision making. January 30, 2019 Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. January 9, 2019 Adverse events and patient outcomes among hospitalized children cared for by general pediatricians vs hospitalists. January 9, 2019 Racial, ethnic, and socioeconomic disparities in patient safety events for hospitalized children. December 19, 2018 Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety. November 7, 2018 Evaluation of accuracy of IHI Trigger Tool in identifying adverse drug events: a prospective observational study. September 12, 2018 Adverse events in hospitalized pediatric patients. July 25, 2018 Inpatient notes: diagnostic excellence starts with an incessant watch. October 25, 2017 Performance of a trigger tool for identifying adverse events in oncology. July 19, 2017 Identifying patients with sepsis on the hospital wards. June 7, 2017 View More See More About The Topic Physicians Health Care Executives and Administrators Diagnostic Errors Audit and Feedback
Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events. February 14, 2018
Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives. November 25, 2020
What interventions could reduce diagnostic error in emergency departments? A review of evidence, practice and consumer perspectives. July 24, 2019
When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine. September 11, 2013
Patient-initiated second opinions: systematic review of characteristics and impact on diagnosis, treatment, and satisfaction. July 15, 2015
Evidence that nurses need to participate in diagnosis: lessons from malpractice claims. April 29, 2020
The effects of a mid-day nap on the neurocognitive performance of first-year medical residents: a controlled interventional pilot study. December 19, 2012
Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events. May 25, 2022
Improving diagnosis by improving education: a policy brief on education in healthcare professions. September 12, 2018
Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review. March 14, 2018
Competencies for improving diagnosis: an interprofessional framework for education and training in health care. August 28, 2019
Identifying trigger concepts to screen emergency department visits for diagnostic errors. December 16, 2020
Hospital computerized provider order entry adoption and quality: an examination of the United States. January 5, 2011
Strategies for developing and recognizing faculty working in quality improvement and patient safety. June 1, 2016
Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers. March 16, 2011
Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fentanyl and patient safety. April 26, 2023
Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? August 25, 2021
Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments. October 26, 2022
Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart failure. August 2, 2023
Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States. June 22, 2022
Association between hospital performance on patient safety and 30-day mortality and unplanned readmission for Medicare fee-for-service patients with acute myocardial infarction. August 3, 2016
Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans — Los Angeles, California, 2020. June 10, 2020
An organisation without a memory: a qualitative study of hospital staff perceptions on reporting and organisational learning for patient safety. November 18, 2015
A novel tool for organisational learning and its impact on safety culture in a hospital dispensary. June 20, 2012
Organisational reporting and learning systems: innovating inside and outside of the box. March 25, 2015
Shape matters: a neglected feature of medication safety: why regulating the shape of medication containers can improve medication safety. February 22, 2023
Time to get off this pig's back?: the human factors aspects of the mismatch between device and real-world knowledge in the health care environment. November 8, 2006
Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. August 15, 2007
Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. July 1, 2020
Opioid medication discontinuation and risk of adverse opioid-related health care events. June 12, 2019
Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. October 7, 2009
Nurse staffing and medication errors: cross-sectional or longitudinal relationships? October 29, 2008
Physician evaluation after medical errors: does having a computer decision aid help or hurt in hindsight? March 1, 2006
The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. February 28, 2007
Burden of difficult encounters in primary care: data from the Minimizing Error, Maximizing Outcomes Study. March 4, 2009
The impact of the COVID-19 pandemic on Emergency Department visits and patient safety in the United States. August 26, 2020
The role of dynamic trade-offs in creating safety—a qualitative study of handover across care boundaries in emergency care. October 28, 2015
A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists. August 27, 2014
Elective surgical patients' narratives of hospitalization: the co-construction of safety. March 5, 2014
Structured communication for patient safety in emergency medical services: a legal case report. May 19, 2010
Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety. March 15, 2023
Eight human factors and ergonomics principles for healthcare artificial intelligence. November 2, 2022
The evolution of the Anesthesia Patient Safety Movement in America: lessons learned and considerations to promote further improvement in patient safety. January 26, 2022
An investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomes. December 13, 2006
Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023
Improving medical residents’ self-assessment of their diagnostic accuracy: does feedback help? February 2, 2022
Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives. November 25, 2020
A program to provide clinicians with feedback on their diagnostic performance in a learning health system. October 28, 2020
Recommendations for using the Revised Safer Dx instrument to help measure and improve diagnostic safety. August 21, 2019
Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. July 10, 2019
Classifying safety events related to diagnostic imaging from a safety reporting system using a human factors framework. May 29, 2019
In-hospital sequelae of injurious falls in 24 medical/surgical units in four hospitals in the United States. March 13, 2019
Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery. March 13, 2019
Comparing the outcomes of reporting and trigger tool methods to capture adverse events in the emergency department. February 27, 2019
Predictors of adverse events and medical errors among adult inpatients of psychiatric units of acute care general hospitals. January 30, 2019
Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. January 9, 2019
Adverse events and patient outcomes among hospitalized children cared for by general pediatricians vs hospitalists. January 9, 2019
Racial, ethnic, and socioeconomic disparities in patient safety events for hospitalized children. December 19, 2018
Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety. November 7, 2018
Evaluation of accuracy of IHI Trigger Tool in identifying adverse drug events: a prospective observational study. September 12, 2018