References

Resource Bibliography

Foundational Set of Readings

Overview

To introduce site visitors – particularly those new to the field of diagnostic error – to the expanding literature base related to the SIDM mission, SIDM shares this selected set of readings to provide grounding in 12 subthemes related to diagnostic error. The list connects readers to articles that cover concepts, challenges and avenues for diagnostic improvement. While the material provides touchstones to primary ideas, its goal is not to stand as a comprehensive record of all the evidence and activity associated with diagnostic error improvement. Nor does it cover news and most lay-press materials. Given is modest length and scope, we provide with the following instructions for use:

  • This list serves as the launch of your journey to explore the diagnostic error literature base. Links to the US National Library of Medicine’s PubMed database have been included to enable readers to utilize the robust search functions in that tool to dig deeper into the content and author output associated with each resource we’ve selected.
  • The subthemes collect the materials in manageable buckets and the placement is fairly subjective. Given how articles can touch on several themes, we have tried to place them in the section that seems most relevant. Materials are not listed in all the places they could be.
  • The collection is focused on current thinking and is therefore is primarily limited to materials published within the last 5 full years. The materials are provided in reverse chronological order so the newer citations will appear at the top of each subtheme collection. A select list of “legacy” materials associated with each theme is also provided. Lastly, we include several seminal special issues as individual resources in the foundational Diagnostic Error 101 section.
  • The list will be updated quarterly. For readers seeking a more in-depth and rapidly curated collection of diagnostic error-related materials, please visit AHRQ PSNet.
  • As much as possible, links to the full text have been provided. Some articles will only be available to subscribers. Please consult a librarian to help obtain full text to those materials.
  • Additional resources can be found throughout the site. Of special note is the Clinical Reasoning Toolkit that shares resources collected to serve as an introduction to clinical reasoning.

 

Subthemes

 




Diagnostic Error 101

Articles in this subtheme broadly discuss diagnostic errors and improvement strategies to outline overarching challenges, factors and solutions from a foundational perspective.

  • Olson APJ, Graber ML, Singh H. Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events. J Gen Intern Med. 2018 Jan 29; [Epub ahead of print].
    PubMed | Free Full Text
  • Khullar D, Jha AK, Jena AB. Reducing diagnostic errors—why now? N Engl J Med. 2015;373(26):2491-2493.
    PubMed | Publisher
  • 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.
    PubMed | Publisher
  • 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.
    PubMed | Free Full Text
  • Berenson RA, Upadhyay D, Kaye DR. Placing Diagnosis Errors on the Policy Agenda. Washington, DC: Urban Institute. Princeton, NJ: Robert Wood Johnson Foundation; 2014.
    NLM Catalog Record | Free Full Text
  • 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.
    PubMed | Free Full Text
  • Groszkruger D. Diagnostic error: untapped potential for improving patient safety? J Healthc Risk Manag. 2014;34(1):38-43.
    PubMedPublisher
  • Schiff GD. Diagnosis and diagnostic errors: time for a new paradigm. BMJ Qual Saf. 2014;23(1):1-3.
    PubMedFree Full Text
  • Graber ML, Wachter RM, Cassel CK. Bringing diagnosis into the quality and safety equations. JAMA. 2012;308(12):1211-1212.
    PubMedPublisher
  • Schiff GD, Leape LL. How can we make diagnosis safer? Acad Med. 2012;87(2):135-138.
    PubMedPublisher

  • Wachter RM. Why diagnostic errors don’t get any respect–and what can be done about them. Health Aff (Millwood). 2010;29(9):1605-1610.
    PubMedFree Full Text
  • Newman-Toker D, Pronovost PJ. Diagnostic errors–the next frontier for patient safety. JAMA 2009;301(10):1060-1062.
    PubMed | Publisher
  • Graber ML. Diagnostic error in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2004;31(2):112-119.
    PubMed | Publisher
  • Graber M, Gordon R, Franklin N. Reducing diagnostic error–what’s the goal? Acad Med. 2002;77(10): 981-992.
    PubMed | Free Full Text

 

  • Bruno MA, Johnson K, Argy N, Graber ML, eds. Improving Diagnosis in Radiology—Progress and Proposals. Diagnosis. 2017;4(3):111-191.
    PubMed CitationsFree 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
  • Plebani M, ed. Errors in Laboratory Medicine and Patient Safety. Clinica Chimica Acta. 2009;404(1):1-86.
    PubMed Citations | Publisher

 




The Extent of Diagnostic Error

Articles in this subtheme explore the scope of diagnostic error, its presence and impact on a global, economic, systemic scale.

  • Gupta A, Snyder A, Kachalia A, Flanders S, Saint S, Chopra V. Malpractice claims related to diagnostic errors in the hospital. BMJ Qual Saf. 2018;27(1):53-60.
    PubMedPublisher
  • 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.
    PubMed | Free Full Text
  • Marshall HS, Milikowski C. Comparison of clinical diagnoses and autopsy findings: six-year retrospective study. Arch Pathol Lab Med. 2017;141(9):1262-1266.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text
  • Zwaan L, Singh H. The challenges in defining and measuring diagnostic error. Diagnosis. 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.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text

 

  • 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.
    PubMedFree Full Text
  • Graber ML, Franklin N, Gordon RR. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.
    PubMed | Free Full Text
  • Singh H, Petersen LA, Thomas EJ. Understanding diagnostic errors in medicine: a lesson from aviation. Qual Saf Health Care. 2006;15(3):159-164.
    PubMed | Publisher



Specialty/Clinical Area Diagnostic Error Concerns

Articles in this subtheme highlight examples of clinical and environmental factors with a focus on distinct specialties, conditions or care delivery environments. The collection is not intended to be comprehensive in this regard, but to provide illustrative examples of both communalities and unique challenges to diagnostic error improvement.

  • Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Neurology. 2017;88(15):1468-1477.
    PubMedPublisher
  • Singh H, Zwaan L. Inpatient notes: reducing diagnostic error—a new horizon of opportunities for hospital medicine. Ann Intern Med. 2016;165:HO2-HO4.
    PSNet | Publisher
  • Arch AE, Weisman DC, Coca S, Nystrom KV, Wira CR 3rd, Schindler JL. Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke. 2016;47(3):668-73.
    PubMed | Free Full Text
  • Rhee C, Kadri SS, Danner RL, et al. Diagnosing sepsis is subjective and highly variable: a survey of intensivists using case vignettes. Crit Care. 2016;20:89.
    PubMed | Publisher
  • Moy E, Barrett M, Coffey R, Hines AL, Newman-Toker DE. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics. Diagnosis. 2015;2(1):29-40.
    PubMed | Free Full Text
  • 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. 2014;1(2):155-166.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text
  • Coon ER, Quinonez RA, Moyer VA, Schroeder AR. Overdiagnosis: how our compulsion for diagnosis may be harming children. Pediatrics. 2014;134(5):1013-1023.
    PubMed | Free Full Text
  • Lee CS, Nagy PG, Weaver SJ, Newman-Toker DE. Cognitive and system factors contributing to diagnostic errors in radiology. AJR Am J Roentgenol. 2013;201(3):611-617.
    PubMed | Publisher
  • 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.
    PubMed | Publisher

 

  • Kostopoulou O, Delaney BC, Munro CW. Diagnostic difficulty and error in primary care–a systematic review. Fam Pract. 2008;25(6):400-413.
    PubMedFree Full Text
  • 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.
    PubMed | Publisher
  • 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(2):206-209.
    PubMed | Publisher
  • Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.
    PubMed | Free Full Text

 




Cognitive Process Considerations

Articles in this subtheme discuss human characteristics that can affect the safety of decision making.

  • 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.
    PubMed | Free Full Text
  • Saposnik G, Redelmeier D, Ruff CC, Tobler PN. Cognitive biases associated with medical decisions: a systematic review. BMC Med Inform Decis Mak. 2016;16(1):138.
    PubMed | Free Full Text
  • Schmidt HG, Mamede S, van den Berge K, van Gog T, van Saase JL, Rikers RM. Exposure to media information about a disease can cause doctors to misdiagnose similar-looking clinical cases. Acad Med. 2014;89(2):285-291.
    PubMed | Free Full Text
  • 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
  • Lee CS, Nagy PG, Weaver SJ, Newman-Toker DE. Cognitive and system factors contributing to diagnostic errors in radiology. Am J Roentgenol. 2013;201(3):611-617.
    PubMed | Free Full Text

 

  • Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003;78(8):775-780.
    PubMedFree Full Text




Individual Reasoning and Decision Making

Articles in this subtheme focus on weaknesses in how conclusions regarding diagnosis are made.

  • Croskerry P, Cosby K, Graber ML, Singh H. Diagnosis: Interpreting the Shadows. Boca Raton, FL: CRC Press; 2017. ISBN: 9781409432333.
    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.
    PubMed | Free Full Text
  • Stark M, Fins JJ. The ethical imperative to think about thinking - diagnostics, metacognition, and medical professionalism. Camb Q Healthc Ethics. 2014;23(4):386-396.
    PubMed | Publisher
  • 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 Feb;89(2):277-284.
    PubMed | Free Full Text

 

  • Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84(8):1022-1028.
    PubMed | Free Full Text
  • Montgomery K. How Doctors Think: Clinical Judgment and the Practice of Medicine. Oxford: Oxford University Press; 2006.
    NLM Record
  • Groopman J. How Doctors Think. Boston, MA: Houghton Mifflin; 2007. ISBN: 0618610030.
  • 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.
    PubMed | Publisher | Free Full Text
  •  Why physicians err in diagnosis. JAMA. 1915;64(13):1076-1077. [Republished in: JAMA. 2015;313(12):1273].
    PubMed | Publisher



The Role of Tests and Laboratory Processes in Diagnostic Error

Articles in this subtheme explore weaknesses in how test results are developed, interpreted and shared as contributors to diagnostic error and delay.

  • 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 Feb 28; [Epub ahead of print].
    PubMedPublisher
  • Institute for Healthcare Improvement, National Patient Safety Foundation. Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. Cambridge, MA: Institute for Healthcare Improvement; 2017.
    Publisher
  • Steelman VM, Williams TL, Szekendi MK, Halverson AL, Dintzis SM, Pavkovic S. Surgical specimen management: a descriptive study of 648 adverse events and near misses. Arch Pathol Lab Med. 2016;140(2):1390-1396.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text
  • Medford-Davis L, Park E, Shlamovitz G, Suliburk J, Meyer AN, Singh H. Diagnostic errors related to acute abdominal pain in the emergency department. Emerg Med J. 2016;33(4):253-259.
    PubMed | Publisher
  • Elmore JG, Longton GM, Carney PA, et al. Diagnostic concordance among pathologists interpreting breast biopsy specimens. JAMA. 2015;313(11):1122-1132.
    PubMed | Free Full Text
  • Carter JL, Coletti RJ, Harris RP. Quantifying and monitoring overdiagnosis in cancer screening: a systematic review of methods. BMJ. 2015;350:g7773.
    PubMed | Free Full Text
  • Donald JJ, Barnard SA. Common patterns in 558 diagnostic radiology errors. J Med Imaging Radiat Oncol. 2012;56(2):173-180.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text

 

  • 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.
    PubMedPublisher
  • Singh H, Thomas EJ, Mani S, et al. Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting. Arch Intern Med. 2009;169(17):1578-1586.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text
  • Bates DW, Leape LL. Doing better with critical test results. Jt Comm J Qual Patient Saf. 2005;31(2):66-67.
    PubMed | Publisher
  • 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.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text



Diagnosis as a Team Sport

Articles in this subtheme explore the value in multidisciplinary contributions to diagnostic improvement through enhancing communication, disclosure and learning.

  • 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.
    PubMed | Publisher
  • Graber ML, Rusz D, Jones ML, et al. The new diagnostic team. Diagnosis. 2017;4(4):225-238.
    PubMed | Free Full Text
  • 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. 2017;4(4):201-224.
    PubMed | Free Full Text
  • 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.
    PubMed | Publisher
  • Nageswaran S, Donoghue N, Mitchell A, Givner LB. An innovative collaborative model of care for undiagnosed complex medical conditions. Pediatrics. 2017;139(5):e20163373.
    PubMed | Free Full Text
  • Taylor JR, Thompson PJ, Genzen JR, Hickner J, Marques MB. Opportunities to enhance laboratory professionals' role on the diagnostic team. Lab Med. 2017;48(1):97-103.
    PubMed | Free Full Text
  • 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.
    PubMed
    | Free Full Text



Individual Skill Interventions and Tools

Articles in this subtheme highlight activities designed to affect how individuals improve the skills needed to support reliable diagnosis.

  • Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89.
    PubMedFree Full Text
  • 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
  • Tudor Car L, Papachristou N, Bull A, et al. Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study. BMC Fam Pract. 2016;17:131.
    PubMed | Free Full Text
  • 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.
    PubMed | Publisher
  • Ely J, Graber MG. Checklists to prevent diagnostic errors: a pilot randomized controlled trial. Diagnosis. 2015;2(3):163–169.
    PubMed | Free Full Text
  • Whiting PF, Davenport C, Jameson C, et al. How well do health professionals interpret diagnostic information? A systematic review. BMJ Open. 2015;5(7):e008155.
    PubMed | Free Full Text
  • Murray DJ, Freeman BD, Boulet JR, Woodhouse J, Fehr JJ, Klingensmith ME. Decision making in trauma settings: simulation to improve diagnostic skills. Simul Healthc. 2015;10(3):139-145.
    PubMed | Free Full Text
  • Hautz WE, Kämmer JE, Schauber SK, Spies CD, Gaissmaier W. Diagnostic performance by medical students working individually or in teams. JAMA. 2015;313(3):303-304.
    PubMed | Free Full Text
  • el Fiol G, Workman TE, Gorman PN. Clinical questions raised by clinicians at the point of care: a systematic review. JAMA Intern Med. 2014;174(5):710-718.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text

 

  • Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med. 2011;86(3):307-313.
    PubMedFree Full Text



Educational Interventions to Improve Diagnosis

Articles in this subtheme highlight approaches to embed diagnostic skill development in to early learning opportunities for clinicians.

  • 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.
    PubMedPublisher
  • 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.
    PubMed | Publisher
  • Trowbridge RL Jr, Rencic JJ, Durning SJ, eds. Teaching Clinical Reasoning. Philadelphia, PA: American College of Physicians; 2015. ISBN: 9781938921056.
    NLM Record
  • Smith BW, Slack MB. The effect of cognitive debiasing training among family medicine residents. Diagnosis. 2015;2(2):117-121.
    PubMed | Free Full Text



Patients and Families as Partners in Diagnostic Error Reduction

Articles in this subtheme discuss both frontline activities to engage patients/families in their own safe diagnosis while expanding the discussion of their role as key partners in systemic improvement work.

  • Berger ZD, Brito JP, Ospina NS, et al. Patient-centred diagnosis: sharing diagnostic decisions with patients in clinical practice. BMJ. 2017;359:j4218.
    PubMedPublisher
  • 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.
    AHRQ PSNet | PubMed | Publisher
  • 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.
    PubMed | Publisher
  • Semigran HL, Linder JA, Gidengil C, Mehrotra A. Evaluation of symptom checkers for self-diagnosis and triage: audit study. BMJ. 2015;351:h3480.
    PubMed | Free Full Text
  • Payne VL, Singh H, Meyer AND, Levy L, Harrison D, Graber ML. Patient-initiated second opinions: systematic review of characteristics and impact on diagnosis, treatment, and satisfaction. Mayo Clin Proc. 2014;89(5):687-696.
    PubMed | Free Full Text
  • Meyer AN, Singh H, Graber ML. Evaluation of outcomes from a national patient-initiated second-opinion program. Am J Med. 2015;128(10):1138.e25-e33.
    PubMed | Free Full Text
  • Wen L, Kosowsky J. When Doctors Don't Listen. New York, NY: St. Martin's Press; 2013. ISBN: 9780312594916.

 

  • Sanders L. Every Patient Tells A Story: Medical Mysteries and the Art of Diagnosis. New York, NY: Broadway Books; 2009. ISBN: 9780767922463.
    NLM Catalog



Culture and Work System Influences on Diagnosis

Articles in this subtheme explore organizational, cultural and environmental factors that manifest themselves in unsafe and unseen conditions that facilitate poor diagnostic performance.

  • Waite S, Scott JM, Legasto A, Kolla S, Gale B, Krupinski EA. Systemic error in radiology. AJR Am J Roentgenol. 2017;209(3):629-639.
    PubMedPublisher
  • 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.
    PubMed | Free Full Text
  • 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.
    PubMed | Publisher
  • Wong SS, Cleverly S, Tan KT, Roche-Nagle G. Impact and culture change after the implementation of a preprocedural checklist in an interventional radiology department. J Patient Saf. 2015 Jul 31; [Epub ahead of print].
    PubMed | Publisher
  • Sarkar U, Simchowitz B, Bonacum D, et al. A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors. Jt Comm J Qual Patient Saf. 2014;40(10):461-461.
    PubMed | Publisher
  • 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. 
    PubMed | Publisher
  • Weed LL, Weed L. Diagnosing diagnostic failure. Diagnosis. 2014;1(1):13–17.
    PubMed | Free Full Text
  • Singh H, Graber ML, Kissam S, et al. System-related interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012.21(2):160-170.
    PubMed | Publisher



Information Technology and Diagnostic Error

Articles in this subtheme focus on technology as a factor in diagnostic error and improvement.

  • 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 Jan 22; [Epub ahead of print].
    PubMedPublisher
  • Mane KK, Rubenstein KB, Nassery N, et al. Diagnostic performance dashboards: tracking diagnostic errors using big data. BMJ Qual Saf. 2018 Mar 17; [Epub ahead of print].
    PubMed | Publisher
  • Graber ML, Byrne C, Johnston D. The impact of electronic health records on diagnosis. Diagnosis. 2017;4(4):211-224.
    PubMed | Free Full Text
  • Porat T, Delaney B, Kostopoulou O. The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients. BMC Med Inform Decis Mak. 2017;17(1):79.
    PubMed | Free Full Text
  • 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 Gen Pract. 2017;67(656):e201-e208.
    AHRQ PSNetPubMed | Free Full Text
  • Semigran HL, Levine DM, Nundy S, Mehrotra A. Comparison of physician and computer diagnostic accuracy. JAMA Intern Med. 2016;176(12):1860-1861.
    PubMed | Free Full Text
  • Amland RC, Hahn-Cover KE. Clinical decision support for early recognition of sepsis. Am J Med Qual. 2016;31(2):103-110.
    PubMed | Free Full Text
  • Murphy DR, Meyer AND, Bhise V, et al. Computerized triggers of big data to detect delays in follow-up of chest imaging results. Chest. 2016;150(3):613-620.
    PubMed | Free Full Text
  • Meyer AND, Longhurst CA, Singh H. Crowdsourcing diagnosis for patients with undiagnosed illnesses: an evaluation of CrowdMed. J Med Internet Res. 2016;18(1):e12.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text
  • 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.
    PubMed | Free Full Text
  • Murphy DR, Wu L, Thomas EJ, Forjuoh SN, Meyer AN, Singh H. Electronic trigger-based intervention to reduce delays in diagnostic evaluation for cancer: a cluster randomized controlled trial. J Clin Oncol. 2015;33(31):3560-3567.
    PubMed | Free Full Text
  • Upadhyay DK, Sittig DF, Singh H. Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records. Diagnosis. 2014;1(4):283.
    AHRQ PSNet | PubMed | Free Full Text

 

  • Schiff GD, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med. 2010;362(12):1066-1069.
    PubMedFree Full Text




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