Foundational Readings
This list serves as the launch of your journey to explore the diagnostic error literature base. The references below link readers to articles that cover concepts, challenges, and avenues for diagnostic improvement.
While this is not a comprehensive list of all the evidence and activity associated with improving diagnosis, these are foundational and current scholarly articles to guide your learning about diagnostic error and the diagnostic process.
If available, links to the full text have been provided as well as links to the PubMed database. Some articles will only be available to subscribers, but libraries can assist in getting full text materials for those without subscriptions.
The collection is primarily limited to materials published within the last five full years, with a select list of legacy materials, dating back further but having significant impact on the field.
Themes
Cognitive Process Considerations
Human characteristics that can affect the safety of decision making.
- Meyer AND, Giardina TD, Khawaja L, et al. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. Patient Educ Couns. 2021;104(11):2606-2615.
PubMed | Publisher
- Ipsaro AJ, Patel SJ, Warner DC, et al. Declaring uncertainty: using quality improvement methods to change the conversation of diagnosis. Hosp Pediatr. 2021;11(4):334-341.
PubMed | Publisher
- Cantey C. The practice of medicine: understanding diagnostic error. J Nurs Pract. 2020;16(8):582-585.
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- Restrepo D, Armstrong KA, Metlay JP. Avoiding cognitive errors in clinical decision making. Ann Intern Med. 2020;172(11):747-751.
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- Carr S. Feedback, on the learning curve to improved diagnosis. ImproveDx. 2020;7(2):1-6.
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- Schnapp BH, Sun JE, Kim JL, Strayer RJ, Shah KH. Cognitive error in an academic emergency department. Diagnosis (Berl). 2018;5(3):135-142.
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- Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and measuring diagnostic uncertainty in medicine: a systematic review. J Gen Intern Med. 2018;33(1):103-115.
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- Zwaan L, Monteiro S, Sherbino J, Ilgen J, Howey B, Norman G. Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. BMJ Qual Saf. 2017;26(2):104-110.
PubMed | Free Full Text
- Braun LT, Zwaan L, Kiesewetter J, Fischer MR, Schmidmaier R. Diagnostic errors by medical students: results of a prospective qualitative study. BMC Med Educ. 2017;17(1):191.
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- Mamede S, van Gog T, van den Berge K, van Saase JL, Schmidt HG. Why do doctors make mistakes? A study of the role of salient distracting clinical features. Acad Med. 2014;89(1):114-120.
PubMed | Free Full Text
- Graber ML, Berner ES, eds. Diagnostic Error: Is Overconfidence the Problem. Amer J Med. 2008;121(suppl):S1-S46.
PubMed Citations | Free Full Text
- Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003;78(8):775-780.
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Culture and Work System Influences on Diagnosis
Organizational, cultural and environmental factors that manifest themselves in unsafe and unseen conditions that facilitate poor diagnostic performance.
- Reece JC, Neal EFG, Nguyen P, et al. Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review. BMC Cancer. 2021;21(1):373.
PubMed | Free Full Text
- Avesar M, Erez A, Essakow J, et al. The effects of rudeness, experience, and perspective-taking on challenging premature closure after pediatric ICU physicians receive hand-off with the wrong diagnosis: a randomized controlled simulation trial. Diagnosis (Berl). 2021;8(3):358-357
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- Singh H, Upadhyay DK, Torretti D. Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan. Acad Med. 2020;95(8):1172-1178.
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- The Guide for Hospital and Health System Leaders for Diagnostic Quality and Safety. Chicago, IL; Society to Improve Diagnosis in Medicine: August 2020.
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- Williams S, Fiumara K, Kachalia A, Desai S. Closing the loop with ambulatory staff on safety reports. Jt Comm J Qual Saf. 2020;46(1):44-50.
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- Campione JR, Mardon RE, McDonald KM. Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error. J Patient Saf. 2019;15(4):267-273.
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- Berenson R, Singh H. Payment innovations to improve diagnostic accuracy and reduce diagnostic error. Health Aff (Millwood). 2018;37(11):1828-1835.
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- Partnership for Health IT Patient Safety. Health IT Safe Practices for Closing the Loop. Plymouth Meeting, PA: ECRI; August 2018.
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- Gupta A, Harrod M, Quinn, et al. Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. Diagnosis (Berl). 2018;5(3):151-156.
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- ALQahtani DA, Rotgans JI, Mamede S, et al. Does time pressure have a negative effect on diagnostic accuracy? Acad Med. 2016;91(5):710-716.
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Diagnosis as a Team Sport
The value in multidisciplinary contributions to diagnostic improvement through enhancing communication, disclosure and learning.
- Rosen M, Ali KJ, Buckley BO, et al. Leadership To Improve Diagnosis: A Call to Action. Rockville, MD: Agency for Healthcare Research and Quality; June 2021. AHRQ Publication No. 20(21)-0040-5-EF.
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- Yousef EA, Sutcliffe KM, McDonald KM, Newman-Toker DE. Crossing academic boundaries for diagnostic safety: 10 complex challenges and potential solutions from clinical perspectives and high-reliability organizing principles. Hum Factors. Epub 2021 Mar 3.
PubMed Publisher
- Gleason KT, Jones R, Rhodes C, et al. Evidence that nurses need to participate in diagnosis: lessons from malpractice claims. J Patient Saf. 2021;17(8):e959-e963.
PubMed Publisher
- Graber ML, Grice GR, Ling LJ, Conway JM, Olson A. Pharmacy education needs to address diagnostic safety. Am J Pharm Educ. 2019;83(6):7442.
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- Verna R, Velazquez AB, Laposata M. Reducing diagnostic errors worldwide through diagnostic management teams. Ann Lab Med. 2019;39(2):121-124.
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- Schiff GD, Bearden T, Hunt LS, et al. Primary care collaboration to improve diagnosis and screening for colorectal cancer. Jt Comm J Qual Patient Saf. 2017;43(7):338–350.
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- Graber ML, Rusz D, Jones ML, et al. The new diagnostic team. Diagnosis.(Berl) 2017;4(4):225-238.
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- Gleason KT, Davidson PM, Tanner EK, et al. Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. Diagnosis (Berl). 2017;4(4):201-224.
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- Lipitz-Snyderman A, Kale M, Robbins L, et al. Peers without fears? Barriers to effective communication among primary care physicians and oncologists about diagnostic delays in cancer. BMJ Qual Saf. 2017;26(11):892-898.
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- Dintzis SM, Clennon EK, Prouty CD, Reich LM, Elmore JG, Gallagher TH. Pathologists' perspectives on disclosing harmful pathology error. Arch Pathol Lab Med. 2017;141(6):841-845.
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Diagnostic Error 101
Overarching challenges, causes and solutions to diagnostic error from a foundational perspective.
- Dave N, Bui S, Morgan C, et al. Interventions targeted at reducing diagnostic error: systematic review. BMJ Qual Saf. Epub 2021 Aug 20
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- Zwaan L, El-Kareh R, Meyer AND, Hooftman J, Singh H. Advancing diagnostic safety research: results of a systematic research priority setting exercise. J Gen Intern Med. 2021;36(10):2943-2951.
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- Hall KK, Shoemaker-Hunt S, Hoffman L, et al. Diagnostic errors. In: Making Healthcare Safer III. A Critical Analysis of Existing and Emerging Patient Safety Practices. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020. AHRQ Publication No. 20-0029-EF.
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- Abimanyi-Ochom J, Bohingamu Mudiyanselage S, Catchpool M, Firipis M, Wanni Arachchige Dona S, Watts JJ. Strategies to reduce diagnostic errors: a systematic review. BMC Med Inform Decis Mak. 2019;19(1):174.
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- Olson APJ, Graber ML, Singh H. Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events. J Gen Intern Med. 2018;33(7):1187-1191.
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- Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf. 2015;24(2):103-110.
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- Graber ML, Trowbridge R, Myers JS, Umscheid CA, Strull W, Kanter MH. The next organizational challenge: finding and addressing diagnostic error. Jt Comm J Qual Patient Saf. 2014;40(3):102-110.
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- Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013;2(Suppl 2):ii21-ii27.
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- Singh H, Giardina TD, Meyer AN, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med. 2013;173(6):418-425.
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- McDonald KM, Matesic B, Contopoulos-Ionnidis DG, et al. Patient safety strategies targeted at diagnostic errors. A systematic review. Ann Intern Med. 2013;158(5 Pt 2):381-389.
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- Schiff GD, Leape LL. How can we make diagnosis safer? Acad Med. 2012;87(2):135-138.
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- Wachter RM. Why diagnostic errors don’t Diagnostic Errors: Technical Series on Safer Primary Care. Geneva, Switzerland: World Health Organization; 2016.
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- Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Improving Diagnosis in Health Care. Washington, DC: National Academies Press; 2015.
NLM Catalog | Free Full Text
- Singh H, Graber ML. Improving diagnosis in health care--the next imperative for patient safety. N Engl J Med. 2015;373(26):2493-2495.
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- get any respect–and what can be done about them. Health Aff (Millwood). 2010;29(9):1605-1610.
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- Newman-Toker D, Pronovost PJ. Diagnostic errors–the next frontier for patient safety. JAMA. 2009;301(10):1060-1062.
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- Graber ML. Diagnostic error in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2004;31(2):112-119.
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- Graber M, Gordon R, Franklin N. Reducing diagnostic error–what’s the goal? Acad Med. 2002;77(10): 981-992.
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- Bruno MA, Johnson K, Argy N, Graber ML, eds. Improving Diagnosis in Radiology—Progress and Proposals. Diagnosis(Berl). 2017;4(3):111-191.
PubMed Citations | Free Full Text
- Singh H, ed. Diagnostic Error in Medicine. BMJ Qual Saf. 2013;22(suppl 2):ii1-ii72.
PubMed Citations | Free Full Text
- Berner ES, Graber ML, eds. Diagnostic Error in Medicine. Adv Health Sci Educ Theory Pract. 2009;14( suppl 1):1-112.
PubMed Citations | Publisher
Disparities in Diagnosis
How ethnic, gender and age factors manifest in implicit biases as contributors to diagnostic error and delay.
- Miller-Kleinhenz JM, Collin LJ, Seidel R, et al. Racial disparities in diagnostic delay among women with breast cancer. J Am Coll Radiol. 2021;18(10):1384-1393.
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- Carr S. Bias in artificial intelligence. ImproveDx. 2021;7(3):
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- Holmes SM, Hansen H, Jenks A, et al. Misdiagnosis, mistreatment, and harm--when medical care ignores social forces. N Engl J Med. 2020;382(12):1083-1086.
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- Slomski A. Why do hundreds of US women die annually in childbirth? JAMA. 2019;321(13):1239-1241.
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- Gara MA, Minsky S, Silverstein SM, Miskimen T, Strakowski SM. A naturalistic study of racial disparities in diagnoses at an outpatient behavioral health clinic. Psychiatr Serv. 2019;70(2):130-134.
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- Dusenbery M. Doing Harm: the Truth about How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick. New York, NY: HarperOne; 2018.
NLM Catalog
- Piccardi C, Detollenaere J, Vanden Bussche P, Willems S. Social disparities in patient safety in primary care: a systematic review. Int J Equity Health. 2018;17(1):114.
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- Weingart SN, Saadeh MG, Simchowitz B, et al. Process of care failures in breast cancer diagnosis. J Gen Intern Med. 2009;24(6):702-709.
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- Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A systematic review of the impact of physician implicit racial bias on clinical decision making. Acad Emerg Med. 2017;24(8):895-904.
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- James SA. The strangest of all encounters: racial and ethnic discrimination in US health care. Cad Saude Publica. 2017;33(Suppl 1):e00104416.
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- Drewniak D, Krones T, Wild V. Do attitudes and behavior of health care professionals exacerbate health care disparities among immigrant and ethnic minority groups? An integrative literature review. Int J Nurs Stud. 2017;70:89-98.
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- Burgess DJ, Beach MC, Saha S. Mindfulness practice: a promising approach to reducing the effects of clinician implicit bias on patients. Patient Educ Couns. 2017;100(2):372-376.
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- Skinner TR, Scott IA, Martin JH. Diagnostic errors in older patients: a systematic review of incidence and potential causes in seven prevalent diseases. Int J Gen Med. 2016;9:137-146.
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- Cwik JC, Papen F, Lemke JE, Margraf J. An investigation of diagnostic accuracy and confidence associated with diagnostic checklists as well as gender biases in relation to mental disorders. Front Psychol. 2016;7:1813.
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- Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60-e76.
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- Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28(11):1504-1510. PubMed | Free Full Text
- Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we go from here? Perm J. 2011;15(2):71-78. PubMed | Free Full Text
- Hicken M, Durkee M, Kravitz-Wurtz N, Jackson J, eds. The Role of Racism in Health Inequalities: Integrating Approaches from Across Disciplines. Soc Sci Med. 2018;199:11-240.
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Educational Interventions to Improve Diagnosis
Approaches to embed diagnostic skill development in to early learning opportunities for clinicians.
- Fernandez Branson C, Williams M, Chan TM, et al. Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. BMJ Qual Saf. 2021;30(12):1002-1009.
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- Royce CS, Hayes MM, Schwartzstein RM. Teaching critical thinking: a case for instruction in cognitive biases to reduce diagnostic errors and improve patient safety. Acad Med. 2019;94(2):187-194.
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- Meyer AND, Upadhyay DK, Collins CA, et al. A program to provide clinicians with feedback on their diagnostic performance in a learning health system. Jt Comm J Qual Patient Saf. 2021;47(2):120-126.
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- Gleason K, Harkless G, Stanley J, Olson APJ, Graber ML. The critical need for nursing education to address the diagnostic process. Nurs Outlook. 2021;69(3):362-369.
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- Russo S, Berg K, Davis J, et al. Incoming interns recognize inadequate physical examination as a cause of patient harm. J Med Educ Curric Dev. 2020;7:2382120520928993.
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- Covin Y, Longo P, Wick N, Gavinski K, Barker B, Wagner J. Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students. Diagnosis (Berl). 2020;8(2):161-166.
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- Olson A, Rencic J, Cosby K, et al. Competencies for improving diagnosis: an interprofessional framework for education and training in health care. Diagnosis (Berl). 2019;6(4):335-341.
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- Daniel M, Rencic J, Durning SJ, et al. Clinical reasoning assessment methods: a scoping review and practical guidance. Acad Med. 2019;94(6):902-912.
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- Feufel MA, Flach JM. Medical education should teach heuristics rather than train them away. Med Educ. 2019;53(4):334-344.
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- Royce CS, Hayes MM, Schwartzstein RM. Teaching critical thinking: a case for instruction in cognitive biases to reduce diagnostic errors and improve patient safety. Acad Med. 2019;94(2):187-194.
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- Trowbridge RL, Reilly JB, Clauser JC, Durning SJ. Using computerized virtual cases to explore diagnostic error in practicing physicians. Diagnosis (Berl). 2018;5(4):229-233.
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- Graber ML, Rencic J, Rusz D, et al. Improving diagnosis by improving education: a policy brief on education in healthcare professions. Diagnosis (Berl). 2018;5(3):107-118.
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- Rencic J, Trowbridge RL Jr, Fagan M, Szauter K, Durning S. Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. J Gen Intern Med. 2017;32(11):1242-1246.
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- Ruedinger E, Olson M, Yee J, Borman-Shoap E, Olson APJ. Education for the next frontier in patient safety: a longitudinal resident curriculum on diagnostic error. Am J Med Qual. 2017;32(6):625-631.
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- Trowbridge RL Jr, Rencic JJ, Durning SJ, eds. Teaching Clinical Reasoning. Philadelphia, PA: American College of Physicians; 2015.
NLM Catalog
- Dhaliwal G, Olson APJ, Singhal G, eds. Health Professions Education. Diagnosis (Berl). 2019;6(2):75-185.
PubMed Citations | Free Full Text
Extent of Diagnostic Error
The scope of diagnostic error, its presence and impact on a global, economic, and systemic scale.
- Cheraghi-Sohi S, Holland F, Singh H, et al. Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices. BMJ Qual Saf. 2021;30(12):977-985.
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- Barwise A, Leppin A, Dong Y, et al. What contributes to diagnostic error or delay? A qualitative exploration across diverse acute care settings in the United States. J Patient Saf. 2021;17(4):239-248.
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- Raffel KE, Kantor MA, Barish P, et al. Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study. BMJ Qual Saf. 2020;29(12):971-979.
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- Gunderson CG, Bilan VP, Holleck JL, et al. Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis. BMJ Qual Saf. 2020;29(12):1008-1018.
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- Newman-Toker DE, Wang Z, Zhu Y, et al. Rate of diagnostic errors and serious misdiagnosis-related harms for major vascular events, infections, and cancers: toward a national incidence estimate using the "Big Three". Diagnosis (Berl). 2020;8(1):67-84.
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- Newman-Toker D, Schaffer A, Yu-Moe C, et al. Serious misdiagnosis-related harms in malpractice claims: the “Big Three”– vascular events, infections, and cancers. Diagnosis (Berl). 2019;6(3):227-240.
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- Marshall HS, Milikowski C. Comparison of clinical diagnoses and autopsy findings: six-year retrospective study. Arch Pathol Lab Med.2017;141(9):1262-1266.
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- Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. The global burden of diagnostic errors in primary care. BMJ Qual Saf. 2017;26(6):484-494.
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- Zwaan L, Singh H. The challenges in defining and measuring diagnostic error. Diagnosis(Berl). 2015;2(2):97-103. PubMed | Free Full Text
- Saber Tehrani AS, 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 Qual Saf. 2013;22(8):672-680.
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- Schwartz A, Weiner SJ, Weaver F, et al. Uncharted territory: measuring costs of diagnostic errors outside the medical record. BMJ Qual Saf.2012;21(11):918-924.
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Incident Reporting and Measurement
Practices that track and measure diagnostic error and its impact.
- Bell SK, Bourgeois FC, DesRoches CM, et al. Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. BMJ Qual Saf. 2021;Epub Oct 16.
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- Griffin JA, Carr K, Bersani K, et al. Analyzing diagnostic errors in the acute setting: a process-driven approach. Diagnosis (Berl). 2021;Epub Aug 23.
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- Carr S. Diagnostic safety event reporting. ImproveDx. July 2021;8(4).
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- Singh H, Bradford A, Goeschel C. Operational Measurement of Diagnostic Safety: State of the Science. Rockville, MD: Agency for Healthcare Research and Quality; April 2020. AHRQ Publication No. 20-0040-1-EF.
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- Gartland RM, Myers LC, Iorgulescu JB, et al. Body of evidence: do autopsy findings impact medical malpractice claim outcomes? J Patient Saf. 2021;17(8):576-582.
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- Perry MF, Melvin JE, Kasick RT, et al. The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors. J Pediatr. 2021;232:257-263.
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- Mahajan P, Pai CW, Cosby KS, et al. Identifying trigger concepts to screen emergency department visits for diagnostic errors. Diagnosis (Berl). 2021;8(3):340-346.
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- Gleason KT, Peterson S, Dennison Himmelfarb CR, et al. Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study. Diagnosis (Berl). 2020;8(2):187-192.
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- Aaronson E, Jansson P, Wittbold K, Flavin S, Borczuk P. Unscheduled return visits to the emergency department with ICU admission: a trigger tool for diagnostic error. Am J Emerg Med. 2020;38(8):1584-1587.
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- Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. Final Report. Washington DC; National Quality Forum: October 6, 2020.
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- Singh H, Bradford A, Goeschel C. Operational measurement of diagnostic safety: state of the science. Diagnosis (Berl). 2020;8(1):51-65.
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- Murphy DR, Meyer AN, Sittig DF, Meeks DW, Thomas EJ, Singh H. Application of electronic trigger tools to identify targets for improving diagnostic safety. BMJ Qual Saf. 2019;28(2):151-159.
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- Hussain F, Cooper A, Carson-Stevens A, et al. Diagnostic error in the emergency department: learning from national patient safety incident report analysis. BMC Emerg Med. 2019;19(1):77.
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- Carr S. Diagnostic error: learning from the past and the present. ImproveDx. 2018;5(3):1-4.
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- Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. BMJ Qual Saf. 2018;27(7):557-566.
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- Dhaliwal G, Shojania KG. The data of diagnostic error: big, large and small. BMJ Qual Saf. 2018;27(7):499-501.
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- Mane KK, Rubenstein KB, Nassery N, et al. Diagnostic performance dashboards: tracking diagnostic errors using big data. BMJ Qual Saf. 2018;27(7):567-570.
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- Jones R, Magee MC. Identifying and learning from events involving diagnostic error: it’s a process. PA Patient Saf Advis. 2018;15(Suppl 1):3-15.
Free full text | Related special supplement
- Murphy DR, Laxmisan A, Reis BA, et al. Electronic health record-based triggers to detect potential delays in cancer diagnosis. BMJ Qual Saf. 2014;23(1):8-16.
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- Schiff GD, Hasan O, Kim S et al. Diagnostic error in medicine–analysis of 583 physician-reported errors. Arch Intern Med. 2009;169(20):1881-1887.
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Individual Reasoning and Decision Making
How conclusions regarding diagnosis are made.
- Scott IA, Hubbard RE, Crock C, et al. Developing critical thinking skills for delivering optimal care. Intern Med J. 2021;51(4):488-493.
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- Croskerry P. The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making. New York, NY: Oxford University Press; 2020. ISBN: 9780190088743.
World Catalog Link
- Mamede S, Hautz WE, Berendonk C, et al. Think twice: effects on diagnostic accuracy of returning to the case to reflect upon the initial diagnosis. Acad Med. 2020;95(8):1223-1229.
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- Connor DM, Durning SJ, Rencic JJ. Clinical reasoning as a core competency. Acad Med. 2020;95(8):1166-1171.
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- Braun LT, Borrmann KF, Lottspeich C, et al. Guessing right - whether and how medical students give incorrect reasons for their correct diagnoses. GMS J Med Educ. 2019;36(6):Doc85.
PubMed | Free Full Text
- Meyer AND, Singh H. The path to diagnostic excellence includes feedback to calibrate how clinicians think. JAMA. 2019;321(8):737-738.
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- Croskerry P, Cosby K, Graber ML, Singh H. Diagnosis: Interpreting the Shadows. Boca Raton, FL: CRC Press; 2017.
NLM Catalog
- Hess BJ, Lipner RS, Thompson V, Holmboe ES, Graber ML. Blink or think: can further reflection improve initial diagnostic impressions? Acad Med. 2015;90(1):112-118.
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- Norman G, Sherbino J, Dore K et al. The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. Acad Med. 2014;89(2):277-284.
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- Dhaliwal G. A piece of my mind. The mechanics of reasoning. JAMA. 2011;306(9):918-919.
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- Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84(8):1022-1028.
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- Groopman J. How Doctors Think. Boston, MA: Houghton Mifflin; 2007. ISBN: 0618610030.
LOC Catalog
- Friedman CP, Gatti GG, Franz TM, et al. Do physicians know when their diagnoses are correct? Implications for decision support and error reduction. J Gen Intern Med. 2005;20(4):334-339.
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- Why physicians err in diagnosis. JAMA. 1915;64(13):1076-1077. [Republished in: JAMA. 2015;313(12):1273].
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Individual Skill Interventions and Tools
Strategies to improve the skills needed to support reliable diagnosis.
- Donner-Banzhoff N, Müller B, Beyer M, Haasenritter J, Seifart C. Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences. Diagnosis (Berl). 2020 26;7(2):115-121.
PubMed Publisher
- Zwaan L, Staal J. Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction. Rockville, MD: Agency for Healthcare Research and Quality; September 2020. AHRQ Publication No. 20-0040-3-EF.
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- Donner-Banzhoff N, Müller B, Beyer M, Haasenritter J, Seifart C. Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences. Diagnosis (Berl). 2020 26;7(2):115-121.
PubMed Publisher
- Meyer AND, Giardina TD, Spitzmueller C, Shahid U, Scott TMT, Singh H. Patient perspectives on the usefulness of an artificial intelligence-assisted symptom checker: cross-sectional survey study. J Med Internet Res. 2020;22(1):e14679.
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- Reisch LM, Prouty CD, Elmore JG, Gallagher TH. Communicating with patients about diagnostic errors in breast cancer care: providers' attitudes, experiences, and advice. Patient Educ Couns. 2020;103(4):833-838.
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- Singh H, Graber ML, Hofer TP. Measures to improve diagnostic safety in clinical practice. J Patient Saf. 2019;15(4):311-316.
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- O'Sullivan ED, Schofield SJ. A cognitive forcing tool to mitigate cognitive bias - a randomized control trial. BMC Med Educ. 2019;19(1):12.
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- Thammasitboon S, Rencic JJ, Trowbridge RL, Olson APJ, Sur M, Dhaliwal G. The Assessment of Reasoning Tool (ART): structuring the conversation between teachers and learners. Diagnosis (Berl). 2018 27;5(4):197-203.
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- Schiff GD, Martin SA, Eidelman DH, et al. Ten principles for more conservative, care-full diagnosis. Ann Intern Med. 2018;169(9):643-645.
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- Meyer AND, Thompson PJ, Khanna A, et al. Evaluating a mobile application for improving clinical laboratory test ordering and diagnosis. J Am Med Inform Assoc. 2018;25(7):841-847.
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- Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89.
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- Lambe KA, O'Reilly G, Kelly BD, Curristan S. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf. 2016;25(10):808-820.
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- Semigran HL, Linder JA, Gidengil C, Mehrotra A. Evaluation of symptom checkers for self-diagnosis and triage: audit study. BMJ. 2015;351:h3480.
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- Reilly JB, Myers JS, Salvador D, Trowbridge RL. Use of a novel, modified fishbone diagram to analyze diagnostic errors. Diagnosis (Berl). 2014;1(2):167-171.
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- Graber ML, Kissam S, Payne V, et al. Cognitive interventions to reduce diagnostic error: a narrative review BMJ Qual Saf. 2012;21(7):535-557.
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- Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med. 2011;86(3):307-313.
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Information Technology and Diagnostic Error
Technology as a factor in diagnostic error and improvement.
- Graber ML, Schrandt S. Improving Telediagnosis--a Call to Action: Final Project Findings. Evanston, IL: Society to Improve Diagnosis in Medicine; September 8, 2021.
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- Smith KM, Hunte HE, Graber ML. Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis. Rockville MD: Agency for Healthcare Research and Quality; August 2020. AHRQ Publication No. 20-0040-2-EF.
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- Partnership for HIT Patient Safety. Implementing Closing the Loop. Safe Practices for Diagnostic Results. Plymouth Meeting, PA: ECRI Institute; 2020.
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- Powell L, Sittig DF, Chrouser K, Singh H. Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care aystem: a qualitative study of aggregated root cause analysis data. JAMA Netw Open. 2020;3(6):e206752.
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- Carayon P, Hoonakker P, Hundt AS, et al. Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study. BMJ Qual Saf. 2020;29(4):329-340.
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- Satterfield K, Rubin JC, Yang D, Friedman CP. Understanding the roles of three academic communities in a prospective learning health ecosystem for diagnostic excellence. Learn Health Syst. 2019;4(1):e210204.
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- Chima S, Reece JC, Milley K, Milton S, McIntosh JG, Emery JD. Decision support tools to improve cancer diagnostic decision making in primary care: a systematic review. Br J Gen Pract. 2019;69(689):e809-e818.
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- Liu X, Faes L, Kale AU et al . A comparison of deep learning performance against health-care professionals in detecting diseases from medical imaging: a systematic review and meta-analysis. Lancet Dig Health. 2019;1(6):e271-e297.
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- Barnett ML, Boddupalli D, Nundy S, Bates DW. Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians. JAMA Netw Open. 2019;2(3):e190096.
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- Graber ML, Byrne C, Johnston D. The impact of electronic health records on diagnosis. Diagnosis (Berl). 2017;4(4):211-224.
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- Kostopoulou O, Porat T, Corrigan D, Mahmoud S, Delaney BC. Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation. Br J GenPract. 2017;67(656):e201-e208.
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- Semigran HL, Levine DM, Nundy S, Mehrotra A. Comparison of physician and computer diagnostic accuracy. JAMA Intern Med. 2016;176(12):1860-1861.
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- Wolf M, Krause J, Carney PA, Bogart A, Kurvers RH. Collective intelligence meets medical decision-making: the collective outperforms the best radiologist. PLoS One. 2015;10(8):e0134269.
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- Schiff GD, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med. 2010;362(12):1066-1069.
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Patients and Families as Partners in Diagnostic Error Reduction
Patient and family engagement in the diagnostic process and their role as key partners in diagnostic improvement.
- Toolkit for Engaging Patients to Improve Diagnostic Safety. Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No. 21-0047-2-EF.
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- Giardina TD, Korukonda S, Shahid U, et al. Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation. BMJ Qual Saf. 2021;30(12):996-1001.
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- Mangus CW, Singh H, Mahajan P. Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments. Rockville, MD: Agency for Healthcare Research and Quality; February 2021.AHRQ Publication No. 20(21)-0040-4-EF.
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- Carr S. Patients gain control of personal health information with the 21st Century Cures Act and OpenNotes. ImproveDx. 2020;7(6):1-5.
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- Patient and Family Advisory Council Leader's Guide for Diagnostic Quality and Safety. Chicago, IL; Society to Improve Diagnosis in Medicine: August 2020.
Publisher
- Sheridan S, Merryweather P, Rusz D, et al. What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors. Washington, DC: National Academy of Medicine; 2020.
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- Sacco AY, Self QR, Worswick EL, et al. Patients' perspectives of diagnostic error: a qualitative study. J Patient Saf. 2021;17(8):e1759-e1764.
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- Blease CR, Bell SK. Patients as diagnostic collaborators: sharing visit notes to promote accuracy and safety. Diagnosis (Berl); 2019;6(3):213-221.
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- Giardina TD, Haskell H, Menon S, et al. Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety. Health Aff (Millwood). 2018;37(11):1821-1827.
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- Miller K, Dastoli A. Matt's story: learning from heartbreak. Int J Qual Health Care. 2018;30(8):654-657.
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- Berger ZD, Brito JP, Ospina NS, et al. Patient-centred diagnosis: sharing diagnostic decisions with patients in clinical practice. BMJ. 2017;359:j4218.
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- Schmidt HG, van Gog T, Schuit SCE, et al. Do patients' disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment. BMJ Qual Saf. 2017;26(1):19-23.
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- Mamede S, Van Gog T, Schuit SC, et al. Why patients' disruptive behaviours impair diagnostic reasoning: a randomised experiment. BMJ Qual Saf. 2017;26(1):13-18.
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- Wen L, Kosowsky J. When Doctors Don't Listen. New York, NY: St. Martin's Press; 2013. ISBN: 9780312594916.
LOC Catalog
- Sanders L. Every Patient Tells A Story: Medical Mysteries and the Art of Diagnosis. New York, NY: Broadway Books; 2009. ISBN: 9780767922463.
NLM Catalog
Role of Tests and Laboratory Processes in Diagnostic Error
How test results are developed, interpreted and shared as contributors can contribute to diagnostic error and delay.
- Lubin IM, Astles J R, Shahangian S, et al. Bringing the clinical laboratory into the strategy to advance diagnostic excellence. Diagnosis (Berl). 2021;8(3):281-294.
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- Zimolzak AJ, Shahid U, Giardina TD et al. Why test results are still getting “lost” to follow-up: a qualitative study of implementation gaps. J Gen Intern Med. Epub 2021 Apr 27.
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- Wright B, Lennox A, Graber ML, Bragge P. Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives. BMC Health Serv Res. 2020;20(1):897.
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- Staats PN, Parkash V, Otis CN, Sharma P, Ioffe O, Bracamonte ER. The current state of communication of urgent and significant, unexpected diagnoses in anatomic pathology. Arch Pathol Lab Med. 2020;144(9):1067-1074.
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- Thomas J, Dahm MR, Li J, ete al. Variation in electronic test results management and its implications for patient safety: A multisite investigation. J Am Med Inform Assoc. 2020;27(8):1214-1224.
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- Advancing safety with closed-loop communication of test results. Quick Safety. December 2019;52:1-3.
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- Bruno MA. Error and Uncertainty in Diagnostic Radiology. New York, NY: Oxford University Press; 2019.
LOC Catalog
- Peck M, Moffat D, Latham B, Badrick T. Review of diagnostic error in anatomical pathology and the role and value of second opinions in error prevention. J Clin Pathol. 2018;71(11):995-1000.
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- Whitehead NS, Williams L, Meleth S, et al. Interventions to improve follow up of laboratory test results pending at discharge: a systematic review. J Hosp Med. 2018;13(9):631-636.
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- Meyer AND, Murphy DR, Singh H. Communicating findings of delayed diagnostic evaluation to primary care providers. J Am Board Fam Med. 2016;29(4):469-473.
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- Carter JL, Coletti RJ, Harris RP. Quantifying and monitoring overdiagnosis in cancer screening: a systematic review of methods. BMJ. 2015;350:g7773.
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- Donald JJ, Barnard SA. Common patterns in 558 diagnostic radiology errors. J Med Imaging Radiat Oncol. 2012;56(2):173-180.
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- Callen JL, Westbrook JI, Georgiou A, Li J. Failure to follow-up test results for ambulatory patients: a systematic review. J Gen Intern Med.2012;27(10):1334-1348.
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- Callen J, Paoloni R, Georgiou A, Prgomet M, Westbrook J. The rate of missed test results in an emergency department. Methods Inf Med.2010;49(1):37-43.
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- Casalino LP, Dunham D, Chin MH, et al. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med.2009;169(12):1123-1129.
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- Singh H, Arora HS, Vij MS, Rao R, Khan MM, Petersen LA. Communication outcomes of critical imaging results in a computerized notification system. J Am Med Inform Assoc. 2007;14(4):459-466.
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- Bates DW, Leape LL. Doing better with critical test results. Jt Comm J Qual Patient Saf. 2005;31(2):66-67.
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- Raab SS, Grzybicki DM, Janosky JE, et al. Clinical impact and frequency of anatomic pathology errors in cancer diagnoses. Cancer. 2005;104(10):2205-2213.
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- 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 Intern Med. 2004;164(20):2223-2228.
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Specialty/Clinical Area Diagnostic Error Concerns
Examples of clinical and environmental factors with a focus on distinct specialties, conditions or care delivery environments.
- Bajaj K, de Roche A, Goffman D. The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.
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- Achieving Excellence in the Diagnosis of Acute Cardiovascular Events: Proceedings of a Workshop–in Brief. National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2021.
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- Cifra CL, Custer JW, Singh H, Fackler JC. Diagnostic errors in pediatric critical care: a systematic review. Pediatr Crit Care Med. 2021;22(8):701-712.
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- Olson APJ, Linzer M, Schiff GD. Measuring and improving diagnostic safety in primary care: addressing the "twin" pandemics of diagnostic error and clinician burnout. J Gen Intern Med. 2021;36(5):1404-1406.
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- Pelaccia T, Messman AM, Kline JA. Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution. Patient Educ Couns. 2020;103(8):1650-1656.
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- Fitzsimons BT, Fitzsimons LL, Sun LR. Laney's story: the problem of delayed diagnosis of pediatric stroke. Pediatrics. 2019;143(4):e20183458.
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- Aaronson EL, Quinn GR, Wong CI, et al. Missed diagnosis of cancer in primary care: insights from malpractice claims data. J Healthc Risk Manag. 2019;39(2):19-29. PubMed | Publisher
- Itri JN, Tappouni RR, McEachern RO, Pesch AJ, Patel SH. Fundamentals of diagnostic error in imaging. Radiographics. 2018;38(6):1845-1865.
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- Obermeyer Z, Cohn B, Wilson M, Jena AB, Cutler DM. Early death after discharge from emergency departments: analysis of national US insurance claims data. BMJ. 2017;356:j239.
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- Okafor N, Payne VL, Chathampally Y, Miller S, Doshi P, Singh H. Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine. Emerg Med J. 2016;33(4):245-252.
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- Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis(Berl). 2014;1(2):155-166.
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- Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf. 2014;23(9):727-731.
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- Coon ER, Quinonez RA, Moyer VA, Schroeder AR. Overdiagnosis: how our compulsion for diagnosis may be harming children. Pediatrics. 2014;134(5):1013-1023.
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- Winters B, Custer J, Galvagno SM, et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf. 2012;21(11):894-902.
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- Kachalia, A, Gandhi TK, Puopolo AL, 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(2):206-209.
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- 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.
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- Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.
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Examine Clinical Reasoning
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