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London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.

Rosen M, Ali KJ, Buckley BO, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2021. AHRQ Publication No. 20(21)-0040-5-EF.

The mindset on diagnostic error improvement has gone from a focus on individual skills to that of system factors. This issue brief highlights the influence health system executives have on amending the care environment to facilitate the most effective environment for diagnostic accuracy. This is part of a publication series examining diagnostic improvement across health care.

Agency for Healthcare Research and Quality. April 2021.

Safe diagnosis in medical offices is challenged by staff workload, communication, and poor information sharing. This Supplemental Item Set for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey (MOSOPS) examines elements contributing to time availability, testing and referrals, and provider and staff communication, and is to be used in conjunction with AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey. The Diagnostic Safety Supplemental Item Set was released in time for the scheduled Fall 2021 MOSOPS data submission.

Constellation, Society to Improve Diagnosis in Medicine. 

The processes supporting safe and accurate diagnosis involve many steps that are prone to human error. This collaborative will engage teams to explore test result management and follow-up coordination to improve timeliness, collaboration, and communication to support safe care. The launch of the collaborative has been delayed due to COVID-19.

The Leapfrog Group.

Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise to be successful. This collaborative initiative will initially develop educational materials to inform health care organization adoption of diagnostic improvement best practices. Building on that experience, a survey component to complement the Leapfrog annual survey will be developed to enhance measurement and motivate improvement.

Organisation for Economic Co-operation and Development.

Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that cover activities and concerns of the 37 member countries active in the organization to address universal challenges to patient safety.

Cumberlege J. London, England, Crown Copyright. July 8, 2020.

Implicit biases are known to affect the safety of health care. This analysis of the National Health Service (NHS) found weaknesses in NHS’ consideration of and response to women’s medication and medical device concerns. Among the recommendations submitted to improve patient centeredness and respect for patients are the establishment of central yet independent authority to serve as the conduit to address patient concerns and improve system safety accountability.
Rockville, MD: Agency for Healthcare Research and Quality. December 27, 2019. Publication No. NOT-HS-20-004.
This announcement highlights AHRQ continued interest in research regarding the development of an evidence base on the incidence of diagnostic error, its presence in a variety of health care environment and its impact on patient outcomes.
PA-PSRS Patient Saf Advis. September 2010;7:76-86.  
Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events.