Resources Related to Diagnostic Safety and Quality

AHRQ Papers on Diagnostic Safety Topics

AHRQ is developing a series of papers on different diagnostic safety issues. Some papers will be posted as Issue Briefs while others will be submitted for publication in peer-reviewed journals.

Issue Briefs

Common Formats for Event Reporting–Diagnostic Safety (CFER–DS)

The Common Formats for Event Reporting - Diagnostic Safety Version 1.0 (CFER-DS V1.0) are designed for use across all healthcare settings and specialties. Widespread use of the CFER-DS and reporting to the PSOPPC/NPSD will make it possible to collect, aggregate and analyze diagnostic safety-related information nationally to accelerate learning and improvement.

AHRQ's Patient Safety Network (PSNet)

PSNet highlights the latest patient safety literature, news, and expert commentary, including weekly updates, Web M&M, Patient Safety Primers, and more. You can search diagnostic error to find related studies and resources.

Symptom-Disease Pair Analysis (SPADE) Research Tool 

Healthcare organizations can use the symptom disease pair analysis (SPADE) Research Tool to:

• Explore rates of potential delayed or missed diagnoses.
• Conduct research within individual hospitals or health systems.
• Identify candidate cases for chart review.
• Support research questions and hypotheses generation. 

Avoid: 

• Using the tool as a definitive estimate of diagnostic error rates.
• Invalid uses such as comparing hospitals or health systems.
• Using the tool for accountability or performance-evaluation purpose.

Journal Articles

• Diagnostic error in mental health: a review. Bradford A, Meyer AND, Khan S, Giardina TD, Singh H. BMJ Qual Saf 2024 Apr 15:bmjqs-2023-016996 (PDF, 979 KB).
• The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: scale development and psychometric evaluation. Ali KJ, Goeschel CA, Eckroade MM, Carlin KN, Haugstetter M, Shofer M, Rosen MA. Jt Comm J Qual Patient Saf 2024 Feb;50(2):95-103 (PDF, 689 KB).
• The PRIDx framework to engage payers in reducing diagnostic errors in health care. Kisha JA, Goeschel CA, DeLia DM, Blackall LM, Singh H. Diagnosis (Berl) 2023 Oct 5;11(1):17-24 (PDF, 1.3 MB).
• Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda. Sloane JF, Donkin C, Newell BR, Singh H, Meyer AND. J Gen Intern Med 2023 May;38(6):1526-1531 (PDF, 289 KB).
• Advancing Diagnostic Equity Through Clinician Engagement, Community Partnerships, and Connected Care. Traber D. Giardina TD, Woodard LD, Singh H. J Gen Intern.Med 2023 Apr;38(5):1293-1295 (PDF, 204 KB).
• Defining diagnostic error: a scoping review to assess the impact of the national academies' report improving diagnosis in health care. Giardina TD, Hunte H, Hill MA, Heimlich SL, Singh H, Smith KM. J Patient Saf 2022 Dec 1;18(8):770-778 (PDF, 990 KB).
• Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events. Bradford A, Shahid U, Schiff GD, Gruber ML, Marinez A, DiStabile P, Timashenka A, Jalal H, Brady PJ. Singh H. J Patient Saf 2022 Sep 1;18(6):521-525 (PDF, 1 MB).
• Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes. Cifra CL, Sittig DF, Singh H. BMJ Qual Saf 2021;30:591-597 (PDF, 283 KB).

AHRQ Views Blogs

• With Increased Funding, AHRQ To Explore Scope and Causes of Diagnostic Errors (March 2019)
• Improving Diagnosis: Patient Safety's Next Great Frontier (October 2016)
• New Coalition Broadens Efforts To Reduce Diagnostic Errors (September 2015)
• New Report Outlines Goals and Recommendations To Reduce Diagnostic Errors (September 2015)