The Agency for Healthcare Research and Quality (AHRQ)'s publications offer practical information to help a variety of health care organizations, providers, and others make care safer in all health care settings.
This issue brief discusses the nurse’s role in diagnostic safety, using the conceptual lens of distributed cognition. It describes the theory of distributed cognition, discusses the nurse’s role in diagnosis through that conceptual lens, and concludes with suggestions for future areas of practice and research.
Publication Date: August 2022 Publication Number: 22-0026-2-EF
The Measure DX Guide is a resource to help healthcare organizations detect, analyze, and learn from diagnostic safety events. Measure Dx can be used by any healthcare organization interested in promoting diagnostic excellence and reducing harm from diagnostic safety events. Potential users include clinicians, quality and safety professionals, risk management professionals, health system leaders, and clinical managers.
Publication Date: July 2022 Publication Number: 22-0038
Diagnostic Safety Issue Brief #7:
Substantial progress is being made in recognizing the need for diagnostic excellence, and improving diagnosis education will be an essential requirement to achieve this goal. This brief highlights the current state of diagnosis education, including gaps; describe innovations with high potential for wider impact; identify key competencies needed to improve diagnostic performance; and describe next steps to ensure progress.
Publication Date: March 2022 Publication Number: 22-0026-1-EF
The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science
Diagnostic Safety Issue Brief #6:
This issue brief discusses what is known about the contribution of diagnostic error to maternal morbidity and mortality, explains the rationale for improvement methods, and outlines the research agenda needed to make progress in this emerging area of diagnostic safety. The brief focuses on the maternal events that occur during childbirth and up to a week postpartum, with maternal hemorrhage as a primary example due to its prevalence, high rate of preventability, and interprofessional effort needed for diagnosis and treatment.
Publication Date: September 2021 Publication Number: 20(21)-0040-6-EF
Diagnostic Safety Issue Brief #5:
Despite the enormous financial cost and patient harm resulting from diagnostic error, many leaders have not
addressed this growing patient safety problem. Healthcare leaders must create a climate that helps diverse,
dynamic, sometimes geographically dispersed diagnostic teams to provide accurate, timely, and fully
communicated diagnoses. Leaders with a growth mindset take on challenges, persist through obstacles, learn
from criticism, and seek inspiration in others' success. This is no small challenge in the face of competing
priorities, but now is the time to begin the journey.
Publication Date: July 2021 Publication Number: 20(21)-0040-5-EF
Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments
Diagnostic Safety Issue Brief #4:
The National Academies of Sciences, Engineering, and Medicine (NASEM) report Improving Diagnosis in Health Care calls for healthcare professionals to engage patients in diagnostic decision making. Patient engagement refers to the concept of patients being actively involved in their healthcare, including but not limited to engaging with medical providers and the health system in diagnosis, treatment, and overall disease management decisions. An increasing body of research shows that patients engaged in their care have improved health outcomes and care experiences.
Publication Date: February 2021 Publication Number: 20(21)-0040-4-EF
For the 17th year in a row, AHRQ is reporting on healthcare quality and disparities. The annual National Healthcare Quality and Disparities Report is mandated by Congress to provide a comprehensive overview of the quality of healthcare received by the general U.S. population and disparities in care experienced by different racial and socioeconomic groups. The report is produced with the help of an Interagency Work Group led by AHRQ.
Publication Date: December 2020 Publication Number: 20(21)-0045-EF
This chartbook provides information regarding disparities in access to and quality of healthcare received by Veterans.
Publication Date: November 2020 Publication Number: 21-0003
Diagnostic Safety Issue Brief #3:
The use of checklists as a tool to improve performance has proven successful in a variety of healthcare settings. For instance, checklists have been successful in preventing hospital-acquired infections and preventing errors in the surgical process. The use of checklists has also been recommended as a tool to reduce diagnostic errors. Diagnostic errors are frequent and often have severe consequences but have received little attention in the field of patient safety.
Checklists are considered a promising intervention for the area of diagnosis because they can support clinicians in their diagnostic decision making by helping them take correct diagnostic steps and ensuring that possible diagnoses are not overlooked. In this issue brief, we summarize current evidence on using checklists to improve diagnostic reasoning.
Publication Date: September 2020 Publication Number: 20-0040-3-EF
Diagnostic Safety Issue Brief #2:
As patients and clinicians participate in telediagnosis at scale, it is vital to consider quality and safety issues that arise when it is used for the diagnosis of acute conditions. What is known? What is not known? Given the likelihood that telehealth will become a mainstay after the current COVID-19 epidemic, we need to learn about optimizing the use of telediagnosis from the massive expansion now in progress and identify emerging research priorities.
Publication Date: August 2020 Publication Number: 20-0040-2-EF