ImproveDX.

Newsletter/Journal

March 26, 2014

Society to Improve Diagnosis in Medicine.

Diagnostic errors have been termed the next frontier in patient safety. To raise awareness of this issue, this occasional newsletter features articles for a multidisciplinary audience that discuss barriers to and solutions for reducing errors related to diagnosis.

Available at

Related Resources From the Same Author(s)

Society to Improve Diagnosis in Medicine. DxQI Seed Grant Program.

December 7, 2021

ACT for Better Diagnosis.

September 19, 2018

Assessment of Reasoning Tool.

November 1, 2017

Fellowship in Diagnostic Excellence.

February 28, 2023

Mark Graber Diagnostic Quality & Safety Award.

August 30, 2023

Taking action to close the loop on diagnostic error: a Constellation and SIDM Collaborative.

June 1, 2021 - June 1, 2022

TeleDx: How is Telemedicine Working - and not Working - to Support Diagnosis?

June 3, 2021 - June 3, 2021

The Guide for Hospital and Health System Leaders for Diagnostic Quality and Safety.

September 16, 2020

Patient and Family Advisory Council Leader's Guide for Diagnostic Quality and Safety.

September 9, 2020

Improving Telediagnosis: A Call to Action.

April 14, 2021

Clinical Reasoning Toolkit.

October 2, 2013

Transforming Education on Diagnostic Reasoning: Ready, Set, Go!

June 2, 2021

Diagnostic Excellence.

October 11, 2017

Diagnostic Error in Medicine 16th International Conference.

October 8, 2023 - October 11, 2023

Patient's Toolkit for Diagnosis.

October 12, 2018

Improving Telediagnosis--a Call to Action: Final Project Findings.

October 13, 2021

Diagnosis.

January 22, 2014

Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process.

November 8, 2017

Diagnostic time-outs to improve diagnosis.

April 20, 2022

A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain.

July 14, 2021

Research to improve diagnosis: time to study the real world.

January 26, 2022

MRI Safety Week.

June 27, 2007

Radiation Oncology Incident Learning System.

January 14, 2015

Narrowing the mindware gap in medicine.

July 20, 2022

Automated identification of diagnostic labelling errors in medicine.

June 8, 2022

Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety.

February 27, 2008

Use of a structured approach and virtual simulation practice to improve diagnostic reasoning.

February 23, 2022

Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study.

December 15, 2021

Advancing Successful Care Transitions to Improve Outcomes.

June 12, 2013

Medication Reconciliation for Hospitalists.

December 18, 2013

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.

December 10, 2008

FIRST Do No Harm.

January 16, 2013

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.

April 22, 2009

Diagnostic error as a result of drug-laboratory test interactions.

March 6, 2019

Quality Improvement and Patient Safety Competencies Across the Learning Continuum.

January 1, 2019

Drive to Deprescribe.

June 23, 2021

Operating at the sharp end: the complexity of human error.

March 6, 2005

Reducing administrative harm in medicine - clinicians and administrators together.

July 6, 2022

Strategies to improve the patient safety outcome indicator: preventing or reducing falls.

April 21, 2005

Effectiveness and efficiency of root cause analysis in medicine.

February 27, 2008

Disclosure of medical errors involving gametes and embryos.

November 9, 2011

Distractors in obstetric ultrasound: do sonographers have safety concerns?

October 9, 2019

Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias.

March 22, 2023

Reducing Adverse Drug Events Related to Opioids Implementation Guide.

January 27, 2016

Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame.

March 29, 2023

Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study.

October 5, 2016

Techniques to improve patient safety in hospitals: what nurse administrators need to know.

September 19, 2012

April 27, 2022

Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and quality for maternal-fetal medicine fellows.

March 22, 2023

Journal Article

Study

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

November 16, 2022

Journal Article

Study

Patient Safety Innovations

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

April 7, 2022

Dual surgeon operating to improve patient safety.

September 29, 2021

Patient generated research priorities to improve diagnostic safety: a systematic prioritization exercise.

April 5, 2023

Serious experience events: applying patient safety concepts to improve patient experience.

July 6, 2022

A quality improvement initiative to improve patient safety event reporting by residents.

February 9, 2022

Indication alerts to improve problem list documentation.

January 26, 2022

Joint Statement on Multiple Patients Per Ventilator.

April 22, 2020

From tasks to processes: the case for changing health information technology to improve health care.

April 1, 2009

The value of learning from near misses to improve patient safety: a scoping review.

January 25, 2023

The efficacy of mindful practice in improving diagnosis in healthcare: a systematic review and evidence synthesis.

October 13, 2021

Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care.

May 25, 2022

The potential of artificial intelligence to improve patient safety: a scoping review.

March 31, 2021

Implementation of participatory organizational change in long term care to improve safety.

September 1, 2021

Using clinical simulation to study how to improve quality and safety in healthcare.

September 29, 2018

Managing interruptions to improve diagnostic decision-making: strategies and recommended research agenda.

March 29, 2023

Standardized orders for titrating vasopressors: do efforts to improve safety slow delivery of care?

September 11, 2019

Healthcare worker serious safety events: applying concepts from patient safety to improve healthcare worker safety.

August 4, 2021

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children.

June 30, 2021

RaDonda Vaught, medication safety, and the profession of pharmacy: steps to improve safety and ensure justice.

August 17, 2022

Leveraging a safety event management system to improve organizational learning and safety culture.

March 30, 2022

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

August 31, 2011

Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety.

February 22, 2023

Dissemination of Lean methods to improve Pap testing quality and patient safety.

April 8, 2008

Psychological intervention to improve communication and patient safety in obstetrics: examination of the health action process approach.

April 13, 2022

Harnessing the power of medical malpractice data to improve patient care.

January 8, 2020

Developing strategic recommendations for implementing smart pumps in advanced healthcare systems to improve intravenous medication safety.

November 16, 2022

Moving beyond the weekend effect: how can we best target interventions to improve patient care?

June 30, 2021

Establishing a multidisciplinary taskforce to improve anticoagulation safety at a large health system.

December 12, 2021

Interventions to improve hand hygiene compliance in patient care.

September 1, 2017

Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.

May 19, 2021

Pharmacist-led program to improve transitions from acute care to skilled nursing facility care.

July 8, 2020

In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments.

June 22, 2022

Engaging with ethnic minority consumers to improve safety in cancer services: a national stakeholder analysis.

May 25, 2022

Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scoping review.

November 11, 2020

Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department.

February 17, 2016

A systems approach to evaluating ionizing radiation: six focus areas to improve quality, efficiency, and patient safety.

June 24, 2015

The impact of an intervention to improve intrapartum maternal vital sign monitoring and reduce alarm fatigue.

April 12, 2023

Human factors and ergonomics to improve performance in intensive care units during the COVID-19 pandemic.

June 2, 2021

Exploring the concept of medication discrepancy within the context of patient safety to improve population health.

December 9, 2009

Medication errors at hospital admission and discharge: risk factors and impact of medication reconciliation process to improve healthcare.

October 20, 2021

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study.

July 29, 2020

A quality improvement initiative using peer audit and feedback to improve compliance with the surgical safety checklist.

July 27, 2022

Laboratory session to improve first-year pharmacy students' knowledge and confidence concerning the prevention of medication errors.

November 11, 2009

Emergency medicine physicians' perspectives on diagnostic accuracy in neurology: a qualitative study.

July 6, 2022

Implementation of a discharge education program to improve transitions of care for patients at high risk of medication errors.

February 19, 2020

Identifying risk in the use of tumor markers to improve patient safety.

May 4, 2016

Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription and administration process.

March 8, 2023

Implementation of safeguards to improve patient safety in chemotherapy.

September 20, 2017

Using consumer engagement strategies to improve healthcare safety for young people: an exploration of the relevance and suitability of current approaches.

November 30, 2022

A systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behaviour.

March 18, 2020

Related Resources

Annual Diagnostic Excellence Summit.

September 27, 2023 - September 27, 2023

Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning.

January 11, 2023

Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief.

July 21, 2022 - July 21, 2022

Improved Diagnostic Accuracy Through Probability-Based Diagnosis.

September 28, 2022

Choosing wisely in clinical practice: embracing critical thinking, striving for safer care.

April 6, 2022

Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study.

February 9, 2022

NAM Scholars in Diagnostic Excellence program.

January 31, 2022

WebM&M Cases

Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax

August 25, 2021

Developing critical thinking skills for delivering optimal care

July 28, 2021

WebM&M Cases

A Sweet Case of Hidden Hydrogen Ions

April 28, 2021

The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making.

January 27, 2021

Diagnostic Excellence Video Series

December 2, 2020

Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. Final Report

October 28, 2020

A program to provide clinicians with feedback on their diagnostic performance in a learning health system.

October 28, 2020

Misdiagnosis, mistreatment, and harm - when medical care ignores social forces.

April 8, 2020

A professional development course improves unprofessional physician behavior.

February 12, 2020

Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.

October 23, 2019

Patient Safety.

September 25, 2019

Missed diagnosis of cancer in primary care: insights from malpractice claims data.

August 7, 2019

Pediatric faculty knowledge and comfort discussing diagnostic errors: a pilot survey to understand barriers to an educational program.

June 12, 2019

Health Professions Education.

June 12, 2019

Systematic error and cognitive bias in obstetric ultrasound.

May 15, 2019

How to reduce maternal mortality rates in the United States.

May 8, 2019

Incidence of multiple sclerosis misdiagnosis in referrals to two academic centers.

May 1, 2019

Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error.

March 27, 2019

Teaching about diagnostic errors through virtual patient cases: a pilot exploration.

February 27, 2019

Testing and improving the acceptability of a web-based platform for collective intelligence to improve diagnostic accuracy in primary care clinics.

February 27, 2019

Evaluation and accurate diagnoses of pediatric diseases using artificial intelligence.

February 27, 2019

A cognitive forcing tool to mitigate cognitive bias—a randomised control trial.

February 20, 2019

Using computerized virtual cases to explore diagnostic error in practicing physicians.

February 13, 2019

See More About The Topic

Physicians

Medicine

Diagnostic Errors

Cognitive Errors ("Mistakes")

Continuing Education

ImproveDX.

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

ImproveDX.

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site