AHRQ Views: Blog posts from AHRQ leaders
AHRQ Expands Its Repertoire to Eliminate Diagnostic Errors
Too many Americans have experienced the health-related consequences and anxieties that follow a diagnostic error – a diagnosis that is either delayed, poorly communicated, or just plain wrong.
Granted, diagnosis can be difficult given the complexities and ambiguities of medical care, and variations in symptoms from one patient to another. Some signs suggest that progress is occurring. However, reliable estimates indicate that diagnostic errors nevertheless remain far too common.
One in 20 adults annually experiences a diagnostic error in outpatient settings. An estimated 250,000 diagnostic errors occur annually in U.S. hospitals. Regardless of the setting, diagnostic errors can derail proper care and may lead to severe injury or death. These issues have been amplified by COVID-19 and its impact on caregivers and the healthcare delivery system.
AHRQ’s newest clinical tool – Measure Dx – is an essential addition to the inventory of resources that can help prevent diagnostic errors. Measure Dx is available to any healthcare organization interested in promoting diagnostic excellence. It is an evidence-based tool that helps identify diagnostic safety events and gain insights for improvement. Measure Dx offers practical guidance and modular, scalable strategies to detect and learn from diagnostic safety events. These strategies are laid out in a four-part guide that provides:
- Strategies to engage people in your organization so that adequate resources are devoted to implementing measurement and learning activities.
- A self-assessment checklist to gauge readiness for implementation, as well as guidance for choosing a measurement strategy that fits within organizational resources.
- Measurement strategies for different types of data sources.
- Recommendations for systematically reviewing and analyzing case data and translating findings into valuable insights for improvement.
Measure Dx exemplifies AHRQ’s continued commitment to diagnostic excellence. These efforts have gained momentum in recent years in critical areas.
Leading Federal efforts: In response to a 2017 Senate report, AHRQ established the Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare. With representation across 12 agencies, the workgroup strives to enhance scientific research as outlined in Improving Diagnosis in Health Care, a milestone 2015 report by the National Academies of Science, Engineering, and Medicine.
Growing the research field: In 2019, Congress authorized $2 million in grants for AHRQ to initiate a research agenda to understand and solve the problem of diagnostic errors. Building on this work, which will be completed in late September, AHRQ announced earlier this year that it would award up to an additional $8 million to support up to 8 Diagnostic Centers of Excellence. These centers will develop expertise in at least one of four areas: error detection and prevention, resilience for safe practice, improving diagnostic precision through consensus, and improving "truth" or diagnostic reference standards. AHRQ funds additional diagnostic safety research through Notice of Funding Opportunities announcements, including the Patient Safety Learning Laboratories and general Program Announcements.
Supporting clinical teams: AHRQ has developed numerous practical tools to advance accurate, timely diagnosis. They include the Toolkit for Engaging Patients To Improve Diagnostic Safety; Diagnostic Safety Issue Briefs that examine current topics and support improvement efforts; a TeamSTEPPS® training program designed specifically for diagnostic improvement; and a recent addition to AHRQ’s Surveys on Patient Safety Culture (SOPS ®) for organizations to gauge support for accurate diagnoses.
Promoting standardized data collection: In May, AHRQ released the Common Formats for Event Reporting - Diagnostic Safety Version 1.0. This resource is intended to help healthcare providers collect diagnostic safety events data in a standardized manner across healthcare settings and specialties. Data analysis can help organizations learn how to improve diagnostic safety and better support clinicians in the diagnostic process. Widespread use will make it possible to collect, aggregate, and analyze diagnostic safety-related information nationwide, which in turn will accelerate learning. Measure Dx recommends using these standard formats for case analysis.
All of AHRQ’s efforts in diagnostic safety – its lead role among Federal agencies, its research investments, its tools, and resources – are aimed at the same goal: to deliver the best possible patient care, especially as we continue to grapple with the COVID-19 pandemic and other public health emergencies. We believe every American deserves a healthcare system that provides timely and accurate diagnoses and care. We hope you find the new Measure Dx tool and the many other AHRQ resources essential additions to your diagnostic safety resources.
Dr. Valdez is Director of AHRQ.