Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. The commentary addresses the importance of early identification and timely intervention in the event of treatment failure and the post-discharge follow-up programs to improve care coordination and communication during transitions of care.

This piece focuses on human factors engineering including application of the SEIPS model to implement care transitions rooted in patient safety and the processes of care.