A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation.

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.^1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

A 63-year-old man presented from a skilled nursing facility (SNF) with shortness of breath and was treated for mild heart failure exacerbation. An echocardiogram was performed but results were pending on discharge, with anticipation that the patient’s primary care provider would follow up the results. Two weeks later, the patient was readmitted from the SNF and was found to have endocarditis and infected pacemaker wires.

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.