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Diagnostic Safety and Quality
Diagnostic errors occur in all settings of care, contribute to about 10 percent of patient deaths, and are the primary reason for medical liability claims. AHRQ is the lead Federal agency investing in research to improve diagnostic safety and reduce diagnostic error.
Since 2007, AHRQ has invested in research to discover findings that advance the knowledge of diagnostic safety and to develop practical tools and resources to improve diagnostic safety. AHRQ funds research to better understand how diagnostic errors happen and what can be done to prevent them.
The September 2016 AHRQ Research Summit on Improving Diagnosis in Health Care explored the state of the science of diagnosis in health care and discussed ways AHRQ and other stakeholders can contribute to a collaborative approach to improving diagnostic performance, as well as identify the research and evidence, tools and training, and data and measures that are needed to improve diagnostic performance.
An article in the June 2017 issue of Diagnosis, authored by members of AHRQ's patient safety team, builds upon themes from the summit by outlining key challenges and areas for potential future research and improvement related to diagnostic errors. Among them are: more robust engagement of patients as an integral part of their health care team; a deeper understanding of diagnostic errors and how to most effectively measure them; successful use of health information technology (IT) to prevent diagnostic error; and structures that optimize how organizations operate and enable better diagnoses for patients.
AHRQ has funded several recent studies on diagnostic error:
- Outpatient diagnostic errors affect 1 in 20 U.S. adults. This study used data from three previous studies of errors in general primary care diagnosis, colorectal cancer diagnosis, and lung cancer diagnosis. The authors estimated that about half of the diagnostic errors they found could have severely harmed patients.
- Pediatricians self-report an appreciable number of diagnostic errors. This study also finds that pediatricians are most interested in preventing high-frequency, non-life-threatening errors. A third (36%) reported no help in diagnostic error reduction from their electronic health record.
- Additional studies and resources can be found by visiting AHRQ's Patient Safety Network and searching for diagnostic error.
Grants Related to Diagnostic Errors
Grants Awarded in Fiscal Year 2019
Recognizing that all Americans can be affected by diagnostic errors, Congress authorized $2 million in fiscal year 2019 for AHRQ to initiate a research agenda to understand and solve the problem. AHRQ has awarded 4 grants that will more precisely define the scope of diagnostic errors. As stated in the fiscal year 2019 request for applications, AHRQ has three key areas of interest:
- Quantifying the incidence of diagnostic errors.
- Understanding what contributes to these errors.
- Learning more about the link between diagnostic errors and outcomes, including adverse events.
Grants Awarded in Fiscal Year 2022
In fiscal year 2022, Congress authorized funding to support AHRQ's research to address failures in the diagnostic process, which may include the establishment of Research Centers of Diagnostic Excellence to develop systems, measures, and new technology solutions to improve diagnostic safety and quality. In response, AHRQ awarded 10 grants to establish Diagnostic Safety Centers of Excellence. As stated in the fiscal year 2022 request for application, AHRQ specified the four following areas of interest:
- Two areas of focus aligned with frontline diagnostician support:
- Safety-I error detection and prevention and Safety-II resilience for safe practice.
- Two additional areas of focus aligned with improving diagnostic systems:
- Improving diagnostic precision through consensus and Improving "truth" or diagnostic reference standards.
Separate grant funding from AHRQ has also supported other diagnostic safety research, including conference grants focused on improving diagnostic safety and quality.
AHRQ tools to reduce diagnostic errors include:
Calibrate Dx is a self-evaluation tool for clinicians to improve their diagnostic decision making. This resource provides structured exercises and tools to help clinicians learn from reviewing their clinical practice. Anyone whose scope of practice includes medical diagnosis can use Calibrate Dx.
Diagnostic Safety Supplemental Items for the Surveys on Patient Safety Culture (SOPS) Medical Office Survey. These supplemental items are designed to be used in conjunction with the core SOPS Medical Office Survey to help medical offices assess the extent to which their organizations support the diagnostic process, accurate diagnoses, and communication around diagnoses.
Guide to Patient and Family Engagement in Hospital Quality and Safety. This guide encourages hospital patients and family members to be involved in their care. It focuses on four primary strategies for promoting patient/family engagement in hospital safety and quality of care:
- Encourage patients and family members to participate as advisors.
- Promote better communication among patients, family members, and health care professionals from the point of admission.
- Implement safe continuity of care by keeping the patient and family informed through nurse bedside change-of-shift reports.
- Engage patients and families in discharge planning throughout the hospital stay.
Learn more about the importance of patient and family engagement with this infographic (PDF, 392 KB).
Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families offers four interventions and four case studies designed to improve patient safety by meaningfully engaging patients and families in their care.
Improving Your Laboratory Testing Process: A Step-by-Step Guide for Rapid-Cycle Patient Safety and Quality Improvement About 40 percent of patient encounters in primary care offices involve some form of medical test. Studies of primary care offices consistently show that the process for managing tests is a significant source of error and patient harm. This toolkit helps ensure that diagnostic lab tests are accurately managed and shared with patients and clinicians in a timely manner. The tools help examine how tests are managed in the office, from the moment tests are ordered until the patient is notified of the test results and the appropriate follow up is determined.
Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events 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.
Questions Are the Answer: Asking questions about a diagnosis or other aspects of care is a step that patients can take to make care safer. Talking with your doctor builds trust and leads to better results, quality, safety, and satisfaction. One of the best ways to communicate with your doctor and health care team is by asking questions. Because time is limited during medical appointments, you will feel less rushed if you prepare your questions before your appointment. These AHRQ resources demonstrate how asking questions can improve care with tips on how to communicate with clinicians.
Reducing Diagnostic Errors in Primary Care Pediatrics Toolkit aims to assist primary care practice teams with a systematic approach to reduce diagnostic errors among children in three important areas: elevated blood pressure, adolescent depression, and actionable pediatric diagnostic tests. This toolkit walks teams through the measurement, screening, recognition, diagnosis, follow-up, and reduction of diagnostic errors in these areas. It is based on clinical evidence, best practices, and a compilation of resources from the project, which involved over 100 primary care physicians and their care teams working across the United States to improve care for children.
Resources To Facilitate Communication Between Patients and Clinicians: From the IOM report, "Improving Diagnosis in Health Care," this toolkit includes a checklist and other resources to help patients understand what they can to do prevent diagnostic error.
TeamSTEPPS for Diagnosis Improvement: TeamSTEPPSÂ® is an evidence-based program built on a framework composed of four teachable, learnable skills-communication, leadership, situation monitoring, and mutual support. The TeamSTEPPSÂ® for Diagnosis Improvement Course applies the TeamSTEPPSÂ® framework to the specific problem of diagnostic error. When implementing TeamSTEPPSÂ® for Diagnosis Improvement, teams will learn about the four skills and how improved communication among all members of the care team can help lead to safer, more accurate, and more timely diagnosis in all healthcare settings.
The Toolkit for Engaging Patients To Improve Diagnostic Safety is designed to promote enhanced communication and information sharing within the patient-provider encounter to help patients, families, and health professionals work together as partners to improve diagnostic safety.
AHRQ Papers on Diagnostic Safety Topics
AHRQ is developing a series of papers on different diagnostic safety issues. Some papers will be posted on the AHRQ website as Issue Briefs while others will be submitted for publication in peer-reviewed journals.
- Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators (PDF, 1.2 MB)
- Improved Diagnostic Accuracy Through Probability-Based Diagnosis (PDF, 976 KB)
- Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (PDF, 1.5 MB)
- Improving Education: A Key to Better Diagnostic Outcomes (PDF, 2 MB)
- The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science (PDF, 1.4 MB)
- Leadership To Improve Diagnosis: A Call to Action (PDF, 2.4 MB)
- Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments (PDF, 2.6 MB)
- Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction (PDF, 971 KB)
- Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis (PDF, 1 MB)
- Operational Measurement of Diagnostic Safety: State of the Science (PDF, 2 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 Jan 25. doi: 10.1007/s11606-022-08019-w. Epub ahead of print. PMID: 36697925 (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 Jan 5. DOI: 10.1007/s11606-022-07966-8 (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 Apr 27 (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 (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;30:591-97 (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)
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.
Common Formats for Event Reporting - Diagnostic Safety (CFER-DS)
In 2015, The National Academies of Sciences, Engineering, and Medicine published a report titled Improving Diagnosis in Health Care. This report was a continuation of two previously published reports from the Institute of Medicine: To Err Is Human: Building a Safer Health System (2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001). These reports bring attention to the specific problem of diagnostic errors and their effect on the quality and safety of healthcare.
In Improving Diagnosis, NASEM outlined eight goals to reduce diagnostic error and improve diagnosis. Goal 8 is to provide dedicated funding for research on the diagnostic process and diagnostic errors. A recommendation for meeting this goal is for Federal agencies to develop a coordinated research agenda on the diagnostic process and diagnostic errors and to commit dedicated funding to implementing this research agenda.
Following the NASEM report, Senate Report 115-150 requested that AHRQ convene a cross-agency work group to address the lack of dedicated research into improving medical diagnosis and in particular, diagnostic failures that lead to patient harm. The Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare was established in response to the Senate Report.
The Workgroup includes members (PDF, 127 KB) from different operating divisions under the U.S. Department of Health and Human Services, as well as representatives from the Department of Defense and the Department of Veterans Affairs.
- November 3, 2022, Meeting Summary (PDF, 163 KB)
- July 25, 2022, Meeting Summary (PDF, 285 KB)
- March 11, 2022, Meeting Summary (PDF, 188 KB)
- November 19, 2021, Meeting Summary (PDF, 309 KB)
- July 22, 2021, Meeting Summary (PDF, 276 KB).
- March 11, 2021, Meeting Summary (PDF, 106 KB).
- November 6, 2020, Meeting Summary (PDF, 193 KB).
- July 23, 2020, Meeting Summary (PDF, 151 KB).
- March 17, 2020, Meeting Summary (PDF, 372 KB).
- November 15, 2019, Meeting Summary (PDF, 76 KB)
- March 8, 2019, Meeting Summary (PDF, 125 KB)
Diagnostic Safety Issue Briefs
Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators (PDF, 1.2 MB)
Improved Diagnostic Accuracy Through Probability-Based Diagnosis (PDF, 976 KB)
Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (PDF, 1.5 MB)
Improving Education—A Key to Better Diagnostic Outcomes (PDF, 2 MB)
The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science (PDF, 1.4 MB)
Leadership To Improve Diagnosis: A Call to Action (PDF, 2.4 MB)
Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments
(PDF, 2.6 MB)
Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction (PDF, 971 KB)
Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis (PDF, 1 MB)
Operational Measurement of Diagnostic Safety: State of the Science (PDF, 2 MB)
Grants Related to Diagnostic Errors
Diagnostic Safety Grants Awarded in FY 2022
Diagnostic Safety Fact Sheet
Improving Diagnosis (PDF, 333 KB)