What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors.

Sue Sheridan; Patricia Merryweather; Diana Rusz; Gordon Schiff

Book/Report

What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors.

March 4, 2020

Sheridan S, Merryweather P, Rusz D, et al. Washington, DC: National Academy of Medicine; 2020.

View more articles from the same authors.

Safety initiatives can be enhanced by engaging patients in the development process. This report highlights one project as an example of how to involve patients as partners in diagnostic improvement research projects. The program resulted in a curriculum that prepared patients to participate as team members in diagnostic improvement studies.

Free full text

Related Resources From the Same Author(s)

Diagnosis and diagnostic errors: time for a new paradigm.

January 8, 2014

A 60-year-old man with delayed care for a renal mass.

May 18, 2011

How can we make diagnosis safer?

February 8, 2012

COVID-19: making the right diagnosis.

August 5, 2020

The elusive and illusive quest for diagnostic safety metrics.

May 16, 2018

Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges.

November 3, 2021

Can electronic clinical documentation help prevent diagnostic errors?

March 31, 2010

Disclosure through our eyes.

March 19, 2008

Advancing the research agenda for diagnostic error reduction.

August 28, 2013

Incorporating indications into medication ordering—time to enter the age of reason.

August 10, 2016

Use of health information technology to reduce diagnostic errors.

August 21, 2013

Strategies for flipping the script on opioid overprescribing.

November 23, 2016

Finding and fixing diagnosis errors: can triggers help?

February 1, 2012

Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors.

September 6, 2017

The vulnerabilities of computerized physician order entry systems: a qualitative study.

December 9, 2015

The global burden of diagnostic errors in primary care.

August 24, 2016

Beyond the prescription: medication monitoring and adverse drug events in older adults.

August 31, 2011

No excuses: the reality that demands action.

September 1, 2005

Improving diagnosis by improving education: a policy brief on education in healthcare professions.

September 12, 2018

Association of note quality and quality of care: a cross-sectional study.

April 23, 2014

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

August 17, 2022

Computerised prescribing for safer medication ordering: still a work in progress.

November 18, 2015

Reduced effectiveness of interruptive drug–drug interaction alerts after conversion to a commercial electronic health record.

May 30, 2018

A prescription for enhancing electronic prescribing safety.

December 12, 2018

Principles of conservative prescribing.

June 29, 2011

Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs.

June 27, 2018

Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders.

July 26, 2017

Addressing ambulatory safety and malpractice: the Massachusetts PROMISES project.

December 14, 2016

Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making.

October 17, 2007

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

August 7, 2019

Indication alerts intercept drug name confusion errors during computerized entry of medication orders.

September 3, 2014

Measuring and improving diagnostic safety in primary care: addressing the “twin” pandemics of diagnostic error and clinician burnout.

March 3, 2021

The new diagnostic team.

November 22, 2017

Competencies for improving diagnosis: an interprofessional framework for education and training in health care.

August 28, 2019

Screening for adverse drug events: a randomized trial of automated calls coupled with phone-based pharmacist counseling.

March 6, 2019

Learning from errors: analysis of medication order voiding in CPOE systems.

March 15, 2017

Screening for medication errors using an outlier detection system.

February 8, 2017

Automated detection of look-alike/sound-alike medication errors.

April 12, 2017

Ensuring primary care diagnostic quality in the era of telemedicine.

October 27, 2021

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors.

August 16, 2017

Primary care closed claims experience of Massachusetts malpractice insurers.

October 16, 2013

Staffing matters—every shift.

December 12, 2012

An initiative to improve the management of clinically significant test results in a large health care network.

October 30, 2013

Junior doctors' views on reporting concerns about patient safety: a qualitative study.

June 17, 2015

Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.

June 8, 2016

Automated detection of wrong-drug prescribing errors.

August 28, 2019

Using a machine learning system to identify and prevent medication prescribing errors: a clinical and cost analysis evaluation.

December 18, 2019

Primary care collaboration to improve diagnosis and screening for colorectal cancer.

May 3, 2017

Doing right by our patients when things go wrong in the ambulatory setting.

February 12, 2014

Systems engineering analysis of diagnostic referral closed-loop processes.

March 9, 2022

Exploration of an automated approach for receiving patient feedback after outpatient acute care visits.

July 30, 2014

Improving diagnosis: adding context to cognition.

September 7, 2022

Personal formularies of primary care physicians across 4 health care systems.

August 4, 2021

Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool.

May 15, 2013

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

February 9, 2022

Labeling solutions and medications in sterile procedural settings.

May 3, 2006

Lessons learned in implementing a chronic opioid therapy management system.

December 21, 2022

Safety concerns of hospital-based new-to-practice registered nurses and their preceptors.

June 23, 2010

Evaluating ambulatory practice safety: the PROMISES Project administrators and practice staff surveys.

December 17, 2014

Diagnostic error in medicine: analysis of 583 physician-reported errors.

November 18, 2009

Impact of vendor computerized physician order entry in community hospitals.

February 22, 2012

Oncology care setting design and planning part I: concepts for the oncology nurse that improve patient safety.

April 30, 2008

A model of chemotherapy education for novice oncology nurses that supports a culture of safety.

October 31, 2007

A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites.

May 10, 2017

Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation.

July 13, 2022

Incorporating medication indications into the prescribing process.

May 9, 2018

Randomized trial of reducing ambulatory malpractice and safety risk: results of the Massachusetts PROMISES Project.

July 19, 2017

Cognitive biases in surgery: systematic review.

March 1, 2023

Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication errors.

October 19, 2016

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

May 25, 2022

Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems.

May 1, 2019

Ten principles for more conservative, care-full diagnosis.

October 10, 2018

"We can't get along without each other": qualitative interviews with physicians about device industry representatives, conflict of interest and patient safety.

May 17, 2017

Impact of electronic health record systems on information integrity: quality and safety implications.

November 13, 2013

Medication error reduction and the use of PDA technology.

April 18, 2007

Failure mode and effect analysis: a technique to prevent chemotherapy errors.

June 28, 2006

Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

December 7, 2022

Pediatric medication safety in the emergency department.

August 27, 2008

Implementing a rapid response team.

November 8, 2006

Structural iatrogenesis—a 43-year-old man with "opioid misuse."

March 6, 2019

Which clinical errors lead to the referral of UK paediatricians to the National Clinical Assessment Service?

June 13, 2012

Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.

December 2, 2020

Fake and expired medications in simulation-based education: an underappreciated risk to patient safety.

March 23, 2016

Medication bar coding: to scan or not to scan?

March 28, 2007

How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions.

July 10, 2019

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

April 27, 2022

HomeNet: ensuring patient safety with medical device use in the home.

June 3, 2009

Adherence to a medication safety protocol: current practice for labeling medications and solutions on the sterile field.

May 26, 2010

Factors influencing the reporting of adverse medical device events: qualitative interviews with physicians about higher risk implantable devices.

March 7, 2018

Analysis of variations in the display of drug names in computerized prescriber-order-entry systems.

May 24, 2017

Adverse events after screening and follow-up colonoscopy.

February 15, 2012

Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members.

September 8, 2010

Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial.

May 29, 2019

DEEP SCOPE: a framework for safe healthcare design.

October 13, 2021

Older adults' perceptions of feeling safe in urban and rural acute care.

March 27, 2013

Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety.

September 11, 2019

Who killed patient safety?

July 20, 2022

Do older patients' perceptions of safety highlight barriers that could make their care safer during organisational care transfers?

January 30, 2005

Assessing clinical handover between paramedics and the trauma team.

September 30, 2009

Related Resources

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

Towards conceptualizing patients as partners in health systems: a systematic review and descriptive synthesis.

March 8, 2023

Association between opioid tapering and subsequent health care use, medication adherence, and chronic condition control.

March 1, 2023

Understanding and Improving Diagnostic Safety in Ambulatory Care.

March 1, 2023

The role of bias in clinical decision-making of people with serious mental illness and medical co-morbidities: a scoping review.

February 22, 2023

Investigating the impact of structural racism on black birthing people - associations between racialized economic segregation, incarceration inequality, and severe maternal morbidity.

February 15, 2023

AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families.

February 15, 2023

The woman who cried pain: do sex-based disparities still exist in the experience and treatment of pain?

February 8, 2023

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

January 25, 2023

Structural racism and adverse maternal health outcomes: a systematic review.

December 21, 2022

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

July 21, 2022 - July 21, 2022

Diagnoses Without Names: Challenges for Medical Care, Research, and Policy.

October 12, 2022

Request for proposals for clinical quality measures to improve diagnosis.

October 6, 2022

Variation in detected adverse events using trigger tools: a systematic review and meta-analysis.

September 21, 2022

Maybe they had a bad day: how LGBTQ and BIPOC patients react to bias in healthcare and struggle to speak out.

September 14, 2022

Opportunities to mine EHRs for malpractice risk management and patient safety.

September 7, 2022

Nurse well-being: a concept analysis.

August 17, 2022

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

August 3, 2022

Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013-20: an observational study of NHS privatisation.

July 20, 2022

Multilevel factors associated with time to biopsy after abnormal screening mammography results by race and ethnicity.

July 6, 2022

Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework.

June 1, 2022

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

May 25, 2022

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

The effect of clinician feedback interventions on opioid prescribing.

April 27, 2022

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

April 20, 2022

Diagnostic error in pediatrics: a narrative review.

March 23, 2022

Improving responses to safety incidents: we need to talk about justice.

February 23, 2022

Characteristics of registered clinical trials assessing strategies of medication errors prevention- an unusual cross sectional analysis.

February 23, 2022

Healing our own: a randomized trial to assess benefits of peer support.

February 2, 2022

See More About The Topic

Researchers

Hospitals

Ambulatory Clinic or Office

Medicine

Diagnostic Errors

What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

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