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JAMA. 2021-2022. 

Diagnostic excellence achievement is becoming a primary focus in health care. This article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges, and priorities for improvement across the system.
Giardina TD, Shahid U, Mushtaq U, et al. J Gen Intern Med. 2022;Epub Jun 1.
Achieving diagnostic safety requires multidisciplinary approaches. Based on interviews with safety leaders across the United States, this article discusses how different organizations approach diagnostic safety. Respondents discuss barriers to implementing diagnostic safety activities as well as strategies to overcome barriers, highlighting the role of patient engagement and dedicated diagnostic safety champions.
Fawzy A, Wu TD, Wang K, et al. JAMA Intern Med. 2022;Epub May 31.
Black and brown patients have experienced disproportionately poorer outcomes from COVID-19 infection as compared with white patients. This study found that patients who identified as Asian, Black, or Hispanic may not have received timely diagnosis or treatment due to inaccurately measured pulse oximetry (SpO2). These inaccuracies and discrepancies should be considered in COVID outcome research as well as other respiratory illnesses that rely on SpO2 measurement for treatment.
Connor DM, Narayana S, Dhaliwal G. Diagnosis (Berl). 2022;9:265-273.
Teaching clinical reasoning to medical students is a key strategy for reducing diagnostic errors. This paper describes a new longitudinal clinical reasoning curriculum taught in a US medical school’s first and second year of medical training. Students reported high self-efficacy after completing the curriculum; however, a competency audit revealed room for improvement in including system-related aspects of care.
Singh M, Collins L, Farrington R, et al. Diagnosis (Berl). 2022;9:184-194.
Clinical reasoning is an essential component of diagnostic safety. This paper describes the development of a new curriculum to improve clinical reasoning skills and processes in medical students. The curriculum uses several educational strategies (e.g., classroom teaching, simulation training, patient encounters) during pre-clerkship and clerkship to improve clinical reasoning skills across several domains (theory, patient assessment, diagnosis, and shared decision-making).
Fontil V, Khoong EC, Lyles C, et al. Jt Comm J Qual Patient Saf. 2022;Epub May 5.
Missed or delayed diagnosis in primary care may result in serious complications for patients. This prospective study followed adults presenting to primary care with new or unresolved symptoms for 12 months. 32% of patients received a diagnosis within one month; most of the rest still did not have a diagnosis at 12 months (50%). The authors suggest interventions aimed at improving diagnosis should be system-based, not specific to a single medical issue or population.
Graber ML, Holmboe ES, Stanley J, et al. Diagnosis (Berl). 2022;9:166-175.
In 2019, a consensus group identified twelve competencies to improve diagnostic education. This article details next steps for incorporating competencies into interprofessional health education: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis.
Hautz WE, Kündig MM, Tschanz R, et al. Diagnosis. 2021;9:241-249.
Diagnostic errors can be identified by measuring concordance of initial and final diagnosis, for instance admission and discharge diagnoses. In this study, researchers developed and tested an automated trigger system to determine concordance between pairs of diagnoses. In comparison to the reference standard (concordance determined by experts) the automated system performance was excellent.
Al-Khafaji J, Townshend RF, Townsend W, et al. BMJ Open. 2022;12:e058219.
Checklists are used to improve patient outcomes in a wide variety of clinical settings and processes, such as childbirth, surgery, and diagnosis. This review applied the Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0) human factors framework to 25 diagnostic checklists. Checklists were characterized within the three primary components (work systems, processes, and outcomes) and subcomponents. Checklists addressing the Task subcomponent were associated with a reduction in diagnostic errors. Several subcomponents were not addressed (e.g. External Environment, Organization) and present an opportunity for future research.
Politi RE, Mills PD, Zubkoff L, et al. J Patient Saf. 2022;Epub Apr 30.
Delays in diagnosis and treatment can lead to poor outcomes for patients. Researchers reviewed root cause analysis (RCA) reports to identify factors contributing to delays in diagnosis and treatment among surgical patients at the Veterans Health Administration. Of the 163 RCAs identified, 73% reflected delays in treatment, 15% reflected delays in diagnosis, and 12% reflected delays in surgery. Policies and processes (e.g., lack of standardized processes, procedures not followed correctly) was the largest contributing factor, followed by communication challenges, and equipment or supply issues.

Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2022. AHRQ Publication No. 22-0027.

A strong safety culture affects practice and learning in health care. This survey of over 1,000 clinicians and staff in 110 medical offices examined the extent to which elements of safety culture support safe diagnosis. Key findings demonstrate strengths in specialist consultation and test result communication. Identified weaknesses included lack of discussions about misdiagnoses when they occurred.
Giardina TD, Hunte H, Hill MA, et al. J Patient Saf. 2022;Epub Apr 27.
The 2015 National Academies of Science, Engineering, and Medicine (NASEM) report Improving Diagnosis in Healthcare defined diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient's health problem(s) or (b) communicate that explanation to the patient.” This review and interviews with subject matter experts explored how the NASEM definition of diagnostic error has been operationalized in the literature. Of the sixteen included studies, only five operationalized the definition and only three studied communicating with the patient. The authors recommend formulating a set of common approaches to operationalize each of the three components of the NASEM definition. Patients and family should be included in defining the construct of “communication to the patient.”
Bradford A, Shahid U, Schiff GD, et al. J Patient Saf. 2022;Epub Apr 21.
Common Formats for Event Reporting allow organizations to collect and share standardized adverse event data. This study conducted a usability assessment of AHRQ’s proposed Common Formats Event Reporting for Diagnostic Safety (CFER-DS). Feedback from eight patient safety experts was generally positive, although they also identified potential reporter burden, with each report taking 30-90 minutes to complete. CFER-DS Version 1.0 is now available.
Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;Epub Apr 21.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.

National Academies of Sciences, Engineering, and Medicine. Arnold and Mabel Beckman Center, Irvine, CA. July 21, 2022, 11:30 AM-6:30 PM (eastern).

The care of older adult patients can be complicated due to comorbidities and polypharmacy. This session will examine diagnostic challenges unique to the older adult population. The existing evidence base and research strategies for the future will be discussed.
Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.
Salwei ME, Hoonakker PLT, Carayon P, et al. Hum Factors. 2022;Epub Apr 4.
Clinical decision support (CDS) systems are designed to improve diagnosis. Researchers surveyed emergency department physicians about their evaluation of human factors-based CDS systems to improve diagnosis of pulmonary embolism. Although perceived usability was high, use of the CDS tool in the real clinical environment was low; the authors identified several barriers to use, including lack of workflow integration.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022.

The COVID-19 crisis affected most health care processes, including diagnosis. This report recaps a session examining impacts of the pandemic on diagnostic approaches, inequities, and innovations that may inform future diagnostic improvement efforts.
Patel SJ, Ipsaro A, Brady PW. Hosp Pediatr. 2022;Epub Feb 28.
Diagnostic uncertainty can arise in complex clinical scenarios. This qualitative study explored how physicians in pediatric emergency and inpatient settings mitigate diagnostic uncertainty. Participants discussed common mitigation strategies, such as employing a “diagnostic pause.” The authors also noted outstanding gaps regarding communicating diagnostic uncertainty to families.
Staal J, Speelman M, Brand R, et al. BMC Med Educ. 2022;22:256.
Diagnostic safety is an essential component of medical training. In this study, medical interns reviewed six clinical cases in which the referral letters from the general practitioner suggested a correct diagnosis, an incorrect diagnosis, or lacked a diagnostic suggestion. Researchers found that diagnostic suggestions in the referral letter did not influence subsequent diagnostic accuracy but did reduce the number of diagnoses considered.