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PSNet: Patient Safety Network
Journal Article

Electronic health record reviews to measure diagnostic uncertainty in primary care.

Bhise V, Rajan SS, Sittig DF, et al. Journal of evaluation in clinical practice. 2018;24:545-551.

Diagnostic error is a type of preventable harm that is particularly difficult to measure. Detecting diagnostic uncertainty is an important precursor to identifying clinical situations at high risk for error. Researchers conducted a retrospective chart review of primary care visits to assess how clinicians described diagnostic uncertainty. They found that diagnostic uncertainty was present in more than two-thirds of visits. Clinicians documented uncertainty in diverse ways—through direct expression in their assessments, by ordering more diagnostic tests, or by scheduling close follow-up. The authors propose that the International Classification of Diseases billing codes include a consistent taxonomy for diagnostic uncertainty. A past PSNet perspective explored advances in diagnostic safety.