From the Field: Coalition Member AHRQ Calls for Focus on Diagnostic Safety Measurement
The Agency for Healthcare Research and Quality (AHRQ) recently released a new issue brief entitled “Operational Measurement of Diagnostic Safety: State of the Science” to advance diagnostic safety measurement and improve patient safety. Recent research has produced guidance for healthcare organizations to improve diagnostic safety through measurement, and the issue brief calls for healthcare organizations to utilize these resources to learn from past diagnostic safety events and proactively monitor for high-risk conditions.
According to researchers, diagnostic errors affect approximately 1 in 20 U.S. adults each year, and these errors occur in all medical care settings, contributing to about 10% of patient deaths. The 2015 National Academies of Sciences, Engineering, and Medicine (NASEM) report Improving Diagnosis in Health Care determines that diagnostic errors are the primary reason for medical liability claims and a significant and under-recognized threat to patient safety.
AHRQ is the lead federal agency investing in research to improve diagnostic safety, and reducing the incidence of diagnostic errors is a priority of the Agency. Few healthcare organizations have implemented systematic measurement of diagnostic errors, but all healthcare organizations would benefit from strategically monitoring diagnostic safety events for learning and improvement.
“We have the opportunity to focus our efforts on advancing diagnostic safety measurement,” said Jeff Brady, MD, MPH, director of the Center for Quality Improvement and Patient Safety at AHRQ. “While we all still have much to learn about how and why diagnostic errors occur, some innovative pioneers have already developed new strategies that could transform the healthcare system’s ability to improve diagnosis.”
Several stakeholders, including AHRQ, the National Quality Forum, the Centers for Medicare & Medicaid Services, the Society to Improve Diagnosis in Medicine, and the Gordon and Betty Moore Foundation, have launched initiatives and research projects to advance development and implementation of diagnostic safety measurement. With these new initiatives in place, healthcare organizations are facing increasing expectations to measure and improve diagnostic safety as part of their quality and safety programs.
According to the brief, substantial effort is still needed to identify research priorities, including how to measure and reduce diagnostic errors, and ensure this information is integrated into practice, where it can translate into benefits for patients.
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