References

Overview of Diagnostic Error

• Newman-Toker D, Pronovost PJ. Diagnostic Errors – The Next Frontier for Patient Safety. JAMA 2009;301(10):1060-1062.
• Graber ML. Diagnostic error in medicine:a case of neglect. Jt Comm J Qual Patient Saf 2004;31(2 (February)):112-119.
• Graber ML et al. Reducing diagnostic error – What’s the goal? Academic Medicine. 2002; 77: 981-992
• Leape LL. Error in medicine. JAMA. 1994 Dec 21;272(23):1851-7.
• Kuhn GJ. Diagnostic errors Acad Emerg Med. 2002 Jul;9(7):740-50
• Montgomery K. How Doctors Think:Clinical Judgment and the Practice of Medicine. Oxford: Oxford University Press; 2006.
• Institute of Medicine. To Err is Human: Building a Safer Health System. Washington DC: National Academy Press 1999
• Wachter RM.Why Diagnostic Errors Don’t Get Any Respect – And What Can Be Done About Them. Health Affairs. 2010; 29: 1605-1610
• Graber ML, Wachter RM, Cassel CK. Bringing diagnosis into the quality and safety equations. JAMA 308, 1211-12, 2012
• Lorincz CY, Drazen E, Sokol PE, Neerukonda KV, Metzger J, Toepp MC, Maul L, Classen DC, Wynia MK. Research in Ambulatory Patient Safety 2000–2010: A 10-Year Review. American Medical Association,Chicago IL 2011.
• Croskerry P. A universal model of diagnostic reasoning. Academic Med 2009. 84:1022-1028
• Newman-Toker DE, McDonald KM, Meltzer DO. How much diagnostic safety can we afford, and how should we decide? A health economics perspective. BMJ Qual Saf 22: ii11-20, 2013.
• Schiff GD. Diagnosis and diagnostic errors: time for a new paradigm. BMJ Qual Saf 22: ii, 2013. doi:10.1136/bmjqs-2013-002426
• Lacker C Diagnostic Error in Acute Care. Pennsylvania Patient Safety Authority 7(3) Sept 76- 86, 2010
• Schiff GD, Leape LL. How can we make diagnosis safer? 87: 135-138, 2012.

 

Incident, Origins of Error

• Schiff GD, Hasan O, Kim S et al. Diagnostic Error in Medicine – Analysis of 583 Physician-Reported Errors. Arch Int Med 2009;169(20):1881-1887
• Wears RL. What makes diagnosis hard? Adv Health Sci Educ Theory Pract 2009;14(Supplement 1):19-25.
• Graber ML, Berner ES, eds. Diagnostic Error: Is Overconfidence the Problem? Am J Med. 2008 May;121(5 Suppl).
• Singh H, Petersen LA, Thomas EJ. Understanding diagnostic errors in medicine: a lesson from aviation. Qual Saf Health Care 2006;15(3):159-164.
• Schiff, GD, Seijeoung, K, Abrams, R, et al. Diagnosing Diagnosis Errors: Lessons from a Multi-Institutional Collaborative Project.Agency for Healthcare Research and Quality (AHRQ) 2005.
• Graber ML, Franklin N, Gordon RR. Diagnostic error in internal medicine. Arch Int Med 2005;165:1493-1499.
• Croskerry P. Diagnostic failure: A cognitive and affective approach. Agency for Healthcare Research Quality; 2005
• Redelmeier. DA., The Cognitive Psychology of Missed Diagnoses, Quality Grand Rounds, Improving Patient Care, Annals of Internal Medicine 2005; 142.
• Friedman, CP., et al. Do Physicians Know When Their Diagnoses are Correct? Implications for Decision Support and Error Reduction. J Gen Intern Med 2005; 20:334-339.
• Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003;78:775-780.
• Voytovich AE., et al. Premature conclusions in diagnostic reasoning, L Med Educ 1985: 60: 302-07
• Tehrani ASS, Lee H, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986-2010: An analysis from the National Practitioner Data Bank. BMJ Quality Safety 2013 DOI 10.1136/bmjqs-2012-001550
• Singh H, Davis T, Meyer, et.al. Types and origins of diagnostic errors in primary care settings. JAMA Online Feb 25, 2013
• Schwartz A, Weiner SJ, Weaver F, et al. Uncharted territory: measuring costs of diagnostic errors outside the medical record. BMJ Qual Saf 21(11):918-24, 2012.
  

Errors in Specialty Areas

• Gandhi TK, Kachalia A, Thomas EJ et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med 2006;145(7):488-496.
• Kostopoulou O, Delaney BC, Munro CW. Diagnostic difficulty and error in primary care – a systematic review. Fam Pract 2008;25:400-413.
• Croskerry P, Wears RL. Safety errors in emergency medicine. In: Markovchick VJ, Pons PT, editors. Philadelphia, PA: Hanley & Belfus, Inc; 2003.
• Moeller JJ, Kurniawan J, Gubitz GJ, Ross JA, Bhan V. Diagnostic accuracy of neurological problems in the emergency department. Can J Neurol Sci 2008;35(3):335-341.
• Kachalia, A., et al. Missed and Delayed Diagnoses in the emergency department: a study of closed malpractice claims form 4 liability insurers., Ann Emerg Med 2007: 49: 206-09.
• Caroll, AE., et al. Malpractice Claims Involving Pediatricians: Epidemiology and Etiology. Pediatrics 2007;120;10-17. www.pediatrics.orgdownloaded March 17, 2008.
• Mendelson, RA., Learning from common diagnostic errors: A case review. AAP News 2007; 28.
• Pines JM. Profiles in patient safety: Confirmation bias in emergency medicine. Academic Emerg Med. 2006;13:90-4
• Kaushal, R., et al. Pediatric Medication Errors: What do we know? What gaps remain? Ambul Pediatrics 2004;4: 73-81.
• Woods, D., Frequency, Types and Severity of Preventable Adverse Events in Children. Abstract Acad Health Serv Res Health Policy Meet. 2002;19:45.
• Hall KK, Schenkel SM, Hirshon JM, Xiao Y, Noskin GA. Incidence and types of non-ideal care events in emergency medicine. Qual Saf Health Care 19 Suppl 3 i20-5, 2010.
• Winters B, Custer J, Galvagno SM, et al. Diagnostic errors in the intensive care unit: A systematic review of autopsy studies. BMJ Qual Saf 21: 894-902, 2012.
  

Cognitive Errors

• Norman G, et al. The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. Acad Med. 2014.
• Mamede S, et al. Why do doctors make mistakes? A study of the role of salient distracting clinical features. Acad Med. 2014.
• Lee CS, et al. Cognitive and system factors contributing to diagnostic errors in radiology. Am J Roentgenol. 2013.
• Van den Berge K, Mamede S. Cognitive diagnostic error in internal medicine. Eur J Intern Med. 2013.
• Kostopoulou O, et al. Information distortion in physicians' diagnostic judgments. Med Decis Making. 2012.
• Ilgen JS, et al. Comparing diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought. Acad Med. 2013.
• Schmidt HG, et al. Exposure to media information about a disease can cause doctors to misdiagnose similar-looking clinical cases. Acad Med. 2014.
  

Errors Related to Diagnostic Testing

• Plebani M. Exploring the iceberg of errors in laboratory medicine. Clin Chem Acta 2009;doi: 10.1016/j.cca.2009.03.022.
• Raab SS. Improving patient safety by examining pathology errors. Clin Lab Med 2004;24(849):863.
• Berlin L. Malpractice issues in radiology: fear of cancer. Am J Roentgenol 2004;183(2):267-272.
• Donald JJ, Barnard SA. Common patterns in 558 diagnostic radiology errors. J Med Imaging Radiat Oncol 56(2): 173-80, 2012.
• Mandel C, Schultz T, Hannaford N, et al. The radiology events register: incident reporting in radiology. European Society of Radiology 2013 doi10.1594/ecr2013/C-2534
• Zhi D, Theisen-Toupal J, Whelan J, Arnaout R. The landscape of inappropriate laboratory testing: A meta-analysis. PLOSone. 8 (11) Nov 2013e78962
  

Errors Related to Communication of Test Results

• Nepple KG, Joudi FN, Hillis SL, Wahls T. Prevalence of delayed clinician response to elevated prostate-specific antigen values. Mayo Clin Proc 2008;83(4 (April)):439-445.
• Wahls T. Diagnostic errors and abnormal diagnostic tests lost to follow-up. J Amb Care Management 2007;30(4 (December)):338-343.
• Cram P, Rosenthal GE, Ohsfeldt R, Wallace RB, Schlechte J, Schiff GD. Failure to recognize and act on abnormal test results: The case of screening bone densitometry. Joint Commission Journal on Quality and Patient Safety 2005;31(February):90-97.
• Singh H, Arora HS, Vij MS, Rao R, Khan MM, Petersen LA. Communication outcomes of critical imaging results in a computerized notification system. JAMIA 2007;14(4 (July)):459-466.
• Singh H, Thomas EJ, Mani S et al. Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting. Arch Int Med 2009;169(17):1578-1586.
• Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. I wish I had seen this test result earlier! Dissatisfaction with test result management in primary care. Arch Int Med 2004;164(Nov 8):2223-2228.
• Bates DW, Leape LL. Doing better with critical test results. Joint Commission Journal on Quality and Patient Safety 2005;31(February):66-67.
• Casalino LP, Dunham D, Chin MH et al. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Int Med 2009;169(12):1123-1129.
• Callen J, Paoloni R, Georgiou A, Prgomet M, Westbrook J. The rate of missed test results in an emergency department. Methods Inf Med 49: 37-43, 2010.
• Callen JL, Westbrook JI, Georgiou A, Li J. Failure to follow-up test results for ambulatory patients: A systematic review. J Gen Intern Med 27(10): 1334-1348, 2012
  
  

Interventions

• Kripalani S, Williams MV, Rask K. Reducing errors in the interpretation of plain radiographs and computed tomography scans. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, editors. Making Health Care Safer. A Critical Analysis of Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; 2001.
• Schiff GD. Minimizing diagnostic error: The importance of follow-up and feedback. Am J Med 2008;121 (5A):S38-S42.
• Graber ML. Taking steps towards a safer future: Measures to promote timely and accurate diagnosis. Am J Med 2008;121(5A):S43.
• Graber M. Educational Interventions to Reduce Diagnostic Error - Can You Teach This Stuff? Adv Health Sci Educ 2009.14:63-69.
• Schiff GD, Bates DW. Can Electronic Clinical Documentation Help Prevent Diagnostic Errors? N Engl J Med. 2010.
• Graber ML, Kissam S, Payne V, et al. Cognitive interventions to reduce diagnostic error: A narrative review. BMJ Quality Safety 2012 DOI10.1136/bmjqs-2011-000149
• Singh H, Graber ML, Kissam S, et al. System-related interventions to reduce diagnostic error: A narrative review. BMJ Quality Safety 2012.21:160-170
• Thammasitiboon S, Cutrer WB. Diagnostic decision-making and strategies to improve diagnosis. Curr Probl Pediatr Adolesc Health Care 43:232-41, 2013
• El-Kareh R, Hasan O, Schiff GD. Use of health information technology to reduce diagnostic errors. BMJ Qual Saf 22 ii40-51, 2013
• Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: Origins of bias and theories of debiasing. BMJ Qual Saf 2013. doi:10.1136/bmjqs-2012-001712
• Croskerry P, Singhal G, Mamede S. Cognitive debiasing 2: Impediments to and strategies for change. BMJ Qual Saf 2013 doi:10.1136/bmjqs-2012-001713
• McDonald KM, Matesic B, Contopoulos-Ionnidis DG, et al. Patient safety strategies targeted at diagnostic errors. A systematic review. Ann Int Med 158 381-389, 2013. 
  

Patient-Focused Interventions 

• The Patient is in: Patient Involvement Strategies for Diagnostic Error Mitigation
• Graber ML. How NOT to be misdiagnosed. Bottom Line – Personal 2007;28:1-3.
• Graber ML. Steering Clear of Diagnostic Errors. In: Corina I, Shapiro E, editors. Family Centered Patient Advocacy Training. Wantagh, NY: PULSE of New York; 2007:50-56.
• Kotz D. Six Secrets to getting the right medical diagnosis. US News and World Report 2009.
  

Checklists

• Gawande A. The Checklist Manifesto - How to Get Things Right. New York, NY: Metropolitan Books; Henry Holt and Company, LLC; 2009.
• Pronovost P, Needham D, Berenholz S, Sinopoli D, Chu H, Cosgrove S, et al.- An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-32.
• Boat AC, Spaeth JP. Handoff -checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Paediatr Anaesth. 2013;23:647-54.
• Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AHS, et al.- A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2010;360:491-9.
• Bordage G.- Why did I miss the diagnosis? Some cognitive explanations and educational implications. Acad Med. 1999;74(10 Suppl):S138-43.
• Graber M, Sorensen A, Biswas J, Modi V, Wackett A, Johnson S, et al.- Developing checklists to prevent diagnostic error in Emergency Room settings. Diagnosis. 2014;1(3):223-31.
• Ely JW, Graber ML, Croskerry P.- Checklists to reduce diagnostic errors. Academic Medicine. 2011;Mar;86(3):307-13.