Operational measurement of diagnostic safety: state of the science.

Hardeep Singh; Andrea Bradford; Christine A. Goeschel

Commentary

Emerging Classic

Operational measurement of diagnostic safety: state of the science.

October 7, 2020

Singh H, Bradford A, Goeschel CA. Diagnosis (Berl). 2021;8(1):51-66.

View more articles from the same authors.

This article discusses the evidence base on operational measurement of diagnostic safety and how health care organizations can measure and learn from diagnostic errors to improve patient safety.

PubMed citation

Free full text

Related AHRQ Issue Brief

Related Resources From the Same Author(s)

Measure Dx: implementing pathways to discover and learn from diagnostic errors.

September 28, 2022

COVID-19: making the right diagnosis.

August 5, 2020

Identifying trigger concepts to screen emergency department visits for diagnostic errors.

December 16, 2020

COVID blindness.

August 5, 2020

Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors.

September 8, 2021

The COVID trap: pediatric diagnostic errors in a pandemic world.

August 25, 2021

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.

August 25, 2021

Narrowing the mindware gap in medicine.

July 20, 2022

Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students.

September 9, 2020

How insight contributes to diagnostic excellence.

September 21, 2022

Improving diagnosis by feedback and deliberate practice: one-on-one coaching for diagnostic maturation.

June 2, 2021

Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method.

August 19, 2020

Understanding context specificity: the effect of contextual factors on clinical reasoning.

September 2, 2020

Bringing the clinical laboratory into the strategy to advance diagnostic excellence.

September 22, 2021

Diagnostic delays in infectious diseases.

September 28, 2022

From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme.

June 15, 2022

Improving diagnostic decision support through deliberate reflection: a proposal.

November 9, 2022

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

February 23, 2022

Analyzing diagnostic errors in the acute setting: a process-driven approach.

October 20, 2021

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

January 11, 2023

Improving diagnosis: adding context to cognition.

September 7, 2022

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

July 14, 2021

A pause in pediatrics: implementation of a pediatric diagnostic time-out.

September 14, 2022

Operational Measurement of Diagnostic Safety: State of the Science.

April 22, 2020

Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events.

May 25, 2022

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

July 6, 2022

A survey of outpatient internal medicine clinician perceptions of diagnostic error.

February 5, 2020

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy.

October 26, 2022

Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system.

May 12, 2021

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

December 15, 2021

A clinical reasoning curriculum for medical students: an interim analysis.

June 22, 2022

An estimate of missed pediatric sepsis in the emergency department.

June 2, 2021

How physicians think: a case-based diagnostic simulation exercise.

September 16, 2020

Strengths and weaknesses in the diagnostic process of endometriosis from the patients' perspective: a focus group study.

September 15, 2021

Evaluation of feedback modalities and preferences regarding feedback on decision-making in a pediatric emergency department.

July 6, 2022

Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients.

May 1, 2020

Human centered design workshops as a meta-solution to diagnostic disparities.

November 2, 2022

Bad things can happen: are medical students aware of patient centered care and safety?

January 25, 2023

The effects of rudeness, experience, and perspective-taking on challenging premature closure after pediatric ICU physicians receive hand-off with the wrong diagnosis: a randomized controlled simulation trial.

December 9, 2020

Affective influences on clinical reasoning and diagnosis: insights from social psychology and new research opportunities.

October 19, 2022

Patient perceptions of misdiagnosis of endometriosis: results from an online national survey.

July 29, 2020

Pursuit of "endpoint diagnoses" as a cognitive forcing strategy to avoid premature diagnostic closure.

December 21, 2022

Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods.

July 21, 2021

Clinical reasoning in the wild: premature closure during the COVID-19 pandemic.

August 19, 2020

Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to address diagnostic errors.

October 12, 2022

Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology.

December 8, 2021

A sociotechnical framework for safety-related electronic health record research reporting: the SAFER reporting framework.

June 24, 2020

Harnessing event report data to identify diagnostic error during the COVID-19 pandemic.

December 15, 2021

Five strategies for clinicians to advance diagnostic excellence.

March 2, 2022

Diagnostic errors in pediatric critical care: a systematic review.

April 28, 2021

Automated identification of diagnostic labelling errors in medicine.

June 8, 2022

Identifying psychiatric diagnostic errors with the Safer Dx Instrument.

September 30, 2020

Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.

March 23, 2022

A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.

December 7, 2022

Time out! Rethinking surgical safety: more than just a checklist.

April 28, 2021

The path to diagnostic excellence includes feedback to calibrate how clinicians think.

February 20, 2019

Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality.

February 16, 2022

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

May 25, 2022

Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices.

June 30, 2021

Prolonged diagnostic intervals as marker of missed diagnostic opportunities in bladder and kidney cancer patients with alarm features: a longitudinal linked data study.

February 17, 2021

Advancing diagnostic equity through clinician engagement, community partnerships, and connected care.

February 22, 2023

Policies to promote shared responsibility for safer electronic health records.

September 29, 2021

The lost sponge: patient safety in the operating room.

October 17, 2012

Fighting a common enemy: a catalyst to close intractable safety gaps.

August 5, 2020

Application of human factors methods to understand missed follow-up of abnormal test results.

November 11, 2020

Diagnostic error in mental health: a review.

April 24, 2024

Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER Guides.

February 16, 2022

Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations.

June 22, 2022

Missed diagnosis of new-onset systolic heart failure at first presentation in children with no known heart disease.

March 6, 2019

The PRIDx framework to engage payers in reducing diagnostic errors in healthcare.

November 1, 2023

Improving diagnostic performance through feedback: the Diagnosis Learning Cycle.

September 1, 2021

Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.

May 12, 2021

Five new ways to advance diagnostic safety in your clinical practice.

August 23, 2023

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

March 29, 2023

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

April 5, 2023

Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.

March 3, 2021

Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes.

June 30, 2021

Application of electronic trigger tools to identify targets for improving diagnostic safety.

October 17, 2018

Health Professions Education.

June 12, 2019

Enhancing safety in high-risk operations: a multilevel analysis of the role of mindful organising in translating safety climate into individual safety behaviours.

April 14, 2021

Exploring nurses' attitudes, skills, and beliefs of medication safety practices.

August 24, 2022

Advancing diagnostic safety research: results of a systematic research priority setting exercise.

February 24, 2021

Applying requisite imagination to safeguard electronic health record transitions.

May 18, 2022

Institutional COVID-19 protocols: focused on preparation, safety, and care consolidation.

September 30, 2020

A call to action: next steps to advance diagnosis education in the health professions.

June 8, 2022

Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data.

July 22, 2020

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

October 28, 2020

Reducing the risk of diagnostic error in the COVID-19 era.

May 27, 2020

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

February 9, 2022

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system.

May 4, 2022

COVID-19: The Diagnostic Challenge.

November 25, 2020

Expert consensus on currently accepted measures of harm.

September 9, 2020

Sensemaking and learning during the Covid-19 pandemic: a complex adaptive systems perspective on policy decision-making.

September 16, 2020

Patient feedback for safety improvement in primary care: results from a feasibility study.

July 29, 2020

Improving patient safety in intensive care units in Michigan.

June 25, 2008

Helping healthcare teams save lives during COVID-19: insights and countermeasures from team science.

November 25, 2020

Resident and nurse perspectives on the use of secure text messaging systems.

October 19, 2022

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

September 2, 2020

The safety journal: lessons learned with an error reporting tool to stimulate systems thinking.

September 12, 2007

Patient safety: honoring advanced directives.

February 21, 2007

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Diagnostic Safety Supplemental Item Set for Medical Office SOPS.

March 4, 2024

Systems approach to suicide prevention: strengthening culture, practice, and education.

June 28, 2023

Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada.

June 28, 2023

VHA's movement for change: implementing high-reliability principles and practices.

May 31, 2023

Learning from errors and resilience.

May 24, 2023

Events that inspired change: the importance of sharing what happened to stop it from happening again.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Quality and safety: learning from the past and (re)imagining the future.

March 29, 2023

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

March 29, 2023

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

March 29, 2023

A high-reliability organization mindset.

February 22, 2023

Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.

November 16, 2022

The debrief imperative: building teaming competencies and team effectiveness.

November 16, 2022

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

November 9, 2022

Veterans Health Administration response to the COVID-19 crisis: surveillance to action.

October 26, 2022

Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to address diagnostic errors.

October 12, 2022

Measure Dx: implementing pathways to discover and learn from diagnostic errors.

September 28, 2022

A health system that won't learn from its mistakes.

September 21, 2022

Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents: an observational study.

September 7, 2022

Positive approaches to safety: learning from what we do well.

August 31, 2022

Criminal liability for nursing and medical harm.

August 3, 2022

Employee silence in health care: charting new avenues for leadership and management.

August 3, 2022

Healthcare Safety Investigations Conference 2022.

August 3, 2022

Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations.

June 22, 2022

Diagnostic Centers of Excellence: Partnerships to Improve Diagnostic Safety and Quality (R18).

April 20, 2022

Crossover of the patient satisfaction surveys, adverse events and patient complaints for continuous improvement in radiotherapy department.

April 20, 2022

Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories.

April 6, 2022

Embracing multiple aims in healthcare improvement and innovation.

March 23, 2022

ASK ME!-Routine measurement of patient experience with patient safety in ambulatory care: a mixed-mode survey

December 22, 2021

See More About The Topic

Hospitals

Ambulatory Clinic or Office

Quality and Safety Professionals

Medicine

Diagnostic Errors

Operational measurement of diagnostic safety: state of the science.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Operational measurement of diagnostic safety: state of the science.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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