When I say…diagnostic error.

Wolf E. Hautz

Commentary

When I say…diagnostic error.

September 26, 2018

Hautz WE. Med Educ. 2018.

View more articles from the same authors.

Inconsistent terminology use in research, education, and measurement strategy development hinders progress and understanding in emergent areas of study. This commentary elaborates how nuances around the use of the term "diagnostic error" in educational or clinical contexts affects its meaning.

PubMed citation

Available at

Related Resources From the Same Author(s)

Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment.

January 26, 2022

Think twice: effects on diagnostic accuracy of returning to the case to reflect upon the initial diagnosis.

September 23, 2020

Automated identification of diagnostic labelling errors in medicine.

June 8, 2022

The potential of collective intelligence in emergency medicine.

May 24, 2017

Diagnostic performance by medical students working individually or in teams.

February 11, 2015

Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review.

November 28, 2018

Safety of clinical and non-clinical decision makers in telephone triage: a narrative review.

April 1, 2015

Assessing resident and attending error and adverse events in the emergency department.

March 2, 2022

Strategies to reduce patient harm from infusion-associated medication errors: a scoping review.

January 31, 2018

Medication errors involving the intravenous administration route: characteristics of voluntarily reported medication errors.

August 10, 2016

Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety.

November 29, 2017

Variability in the measurement of hospital-wide mortality rates.

March 19, 2014

Characteristics of medical liability claims against dermatologists from 1991 through 2015.

December 20, 2017

Making care better in the pediatric intensive care unit.

January 30, 2019

Implicit bias in stroke care: a recurring old problem in the rising incidence of young stroke.

January 27, 2021

The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.

September 15, 2010

Can medical record reviewers reliably identify errors and adverse events in the ED?

May 25, 2016

Cold debriefings after in-hospital cardiac arrest in an international pediatric resuscitation quality improvement collaborative.

September 2, 2020

Medication safety in the operating room: literature and expert-based recommendations.

February 22, 2017

Ethical considerations on disclosure when medical error is discovered during medicolegal death investigation.

September 20, 2017

The prevalence of second victim syndrome and emotional distress in pediatric intensive care providers.

June 21, 2023

The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: a critical role for subjective advocates.

July 14, 2021

The effect of visitation restrictions on ED error.

March 6, 2024

Characteristics of medication errors made by students during the administration phase: a descriptive study.

February 22, 2006

Driving improvement in patient care: lessons from Toyota.

March 6, 2005

A relational leadership perspective on unit-level safety climate.

November 9, 2011

Nursing student medication errors involving tubing and catheters: a descriptive study.

May 13, 2009

Evaluation of detected medication errors within the operating room at an academic medical center.

June 21, 2023

Can asking emergency physicians whether or not they would have done something differently (WYHDSD) be a useful screening tool to identify emergency department error?

October 11, 2023

Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists.

October 24, 2007

Collective intelligence meets medical decision-making: the collective outperforms the best radiologist.

September 9, 2015

A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: a prospective observational study.

June 21, 2017

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

July 20, 2022

What patients think doctors know: beliefs about provider knowledge as barriers to safe medication use.

August 14, 2013

Limited health literacy is a barrier to medication reconciliation in ambulatory care.

October 31, 2007

Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.

December 8, 2010

Medication reconciliation and hypertension control.

March 24, 2010

COVID-19: an emerging threat to antibiotic stewardship in the emergency department.

October 21, 2020

Reducing prescribing errors in hospitalized children on the ketogenic diet.

February 24, 2021

Call to action: addressing pediatric fall safety in ambulatory environments.

December 1, 2021

Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients.

December 14, 2005

Understanding the cognitive work of nursing in the acute care environment.

October 19, 2005

The use of medical emergency teams in medical and surgical patients: impact of patient, nurse and organisational characteristics.

October 29, 2008

Misunderstanding of prescription drug warning labels among patients with low literacy.

June 7, 2006

Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update.

June 22, 2022

Health literacy and mortality among elderly persons.

August 8, 2007

Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes.

May 25, 2016

What did the doctor say? Health literacy and recall of medical instructions.

May 16, 2012

Diagnostic inaccuracy of smartphone applications for melanoma detection.

January 30, 2013

Variability in pharmacy interpretations of physician prescriptions.

March 4, 2009

Patient-centered approach for improving prescription drug warning labels.

September 24, 2008

Predictors of misunderstanding pediatric liquid medication instructions.

December 9, 2009

Strategies to prevent missed nursing care: an international qualitative study based upon a positive deviance approach.

May 12, 2021

The effects of stress and coping on surgical performance during simulations.

January 13, 2010

Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults.

September 6, 2023

Improving patient understanding of prescription drug label instructions.

January 21, 2009

The variability and quality of medication container labels.

September 19, 2007

Literacy and misunderstanding prescription drug labels.

December 13, 2006

Human factors and ergonomics and quality improvement science: integrating approaches for safety in healthcare.

April 1, 2015

Boosting medical diagnostics by pooling independent judgments.

August 17, 2016

The human face of simulation: patient-focused simulation training.

October 18, 2006

Visual acuity, literacy, and unintentional misuse of nonprescription medications.

June 13, 2018

Doctors charged with manslaughter in the course of medical practice, 1795-2005: a literature review.

July 19, 2006

Changing conversations: teaching safety and quality in residency training.

November 19, 2008

To err is human: patient misinterpretations of prescription drug label instructions.

November 7, 2007

Parents' medication administration errors: role of dosing instruments and health literacy.

February 10, 2010

Incidence, nature and impact of error in surgery.

August 3, 2011

Discussing the undiscussable with the powerful: why and how faculty must learn to counteract organizational silence.

August 13, 2014

Defining and classifying medical error: lessons for patient safety reporting systems.

March 6, 2005

The hazards of hospitalization.

March 6, 2005

Handoff strategies in settings with high consequences for failure: lessons for health care operations.

March 6, 2005

Helping patients simplify and safely use complex prescription regimens.

March 16, 2011

Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care.

June 22, 2016

Risk of unintentional overdose with non-prescription acetaminophen products.

June 20, 2012

Rapid response teams seen through the eyes of the nurse.

August 4, 2010

Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system.

May 6, 2015

Associations between communication climate and the frequency of medical error reporting among pharmacists within an inpatient setting.

September 25, 2013

Embedding quality and safety in otolaryngology–head and neck surgery education.

January 21, 2015

Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a tracheostomy.

July 18, 2007

Improving prescription drug warnings to promote patient comprehension.

January 20, 2010

The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities.

December 6, 2017

The influence of the structure and culture of medical group practices on prescription drug errors.

August 31, 2005

Radically redesigning patient safety.

May 4, 2016

Infections and interaction rituals in the organisation: clinician accounts of speaking up or remaining silent in the face of threats to patient safety.

December 16, 2015

High fidelity simulation as a research tool.

February 29, 2012

A spotlight on strategies for increasing safety reporting in nursing education.

January 4, 2012

Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills.

December 21, 2011

High-fidelity simulation and safety: an integrative review.

December 19, 2012

Medication safety in the neonatal intensive care unit: big measures for our smallest patients.

March 8, 2017

Seeing risk and allocating responsibility: talk of culture and its consequences on the work of patient safety.

December 10, 2014

Multidisciplinary in-hospital teams improve patient outcomes: a review.

October 22, 2014

The risks of the prescribing cascade.

September 16, 2020

Single-patient rooms for safe patient-centered hospitals.

September 10, 2008

Patient Safety and Quality Improvement Act of 2005.

May 10, 2006

Implementing a rapid response team.

November 8, 2006

The 80-hour duty week: rationale, early attitudes, and future questions.

September 20, 2006

A transdisciplinary team acting on evidence through analyses of moot malpractice cases.

July 11, 2007

Pharmacist involvement in a rapid-response team at a community hospital.

April 18, 2007

Patient safety and error reduction in surgical pathology.

February 20, 2008

A piece of my mind. Copy-and-paste.

June 14, 2006

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Context matters: toward a multilevel perspective on context in clinical reasoning and error.

June 21, 2023

Listen to the whispers before they become screams: addressing Black maternal morbidity and mortality in the United States.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Crisis scenarios for simulation-based nontechnical skills training for cardiac surgery teams: a national survey among cardiac anesthesiologists, cardiac surgeons, clinical perfusionists, and cardiac operating room nurses.

April 12, 2023

Managing interruptions to improve diagnostic decision-making: strategies and recommended research agenda.

March 29, 2023

The REPAIR Project: a prospectus for change toward racial justice in medical education and health sciences research: REPAIR project steering committee.

January 11, 2023

Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study.

November 2, 2022

Affective influences on clinical reasoning and diagnosis: insights from social psychology and new research opportunities.

October 19, 2022

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

August 3, 2022

Safety-II and the study of healthcare safety routines: two paths forward for research.

July 13, 2022

Instruments for measuring patient safety competencies in nursing: a scoping review.

June 15, 2022

Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions.

November 10, 2021

Effectiveness of communication interventions in obstetrics--a systematic review.

April 21, 2021

Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution.

November 11, 2020

Operational measurement of diagnostic safety: state of the science.

October 7, 2020

COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought.

August 19, 2020

The patient died: what about involvement in the investigation process?

June 24, 2020

The flaw of medicine: addressing racial and gender disparities in critical care.

May 27, 2020

The next step in learning from sentinel events in healthcare.

April 15, 2020

What are we doing when we double check?

April 1, 2020

Adverse medication events related to hospitalization in the United States: a comparison between adults with intellectual and developmental disabilities and those without.

February 5, 2020

Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems.

February 2, 2020

Safety culture across cultures.

January 8, 2020

Impact of weekend effect on postoperative mortality in patients undergoing emergency General surgery procedures: meta-analysis of prospectively maintained national databases across the world.

November 13, 2019

The need for surgical safety checklists in neurosurgery now and in the future - a systematic review.

October 30, 2019

Allowing failure for educational purposes in postgraduate clinical training: a narrative review.

July 24, 2019

Teaching medical students to recognise and report errors.

July 10, 2019

Deprescribing Guidelines: Special Section on Symposium Results.

June 26, 2019

Health Professions Education.

June 12, 2019

See More About The Topic

When I say…diagnostic error.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

When I say…diagnostic error.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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