Overview of Diagnostic Error Case Review for Learning

Systematically learn from diagnostic errors so changes can be made to reduce the risk of error

An organization identifies cases that are potentially diagnostic errors and has individuals (often diagnosticians or multiple reviews) use a structured approach (SaferDx) tool to review diagnostic errors once they are identified. A multidisciplinary team is convened to do a root cause analysis using the diagnostic error fishbone tool to identify contributing factors and identify countermeasures to reduce risk of error in the future. Data on the types of cases, contributing factors, and actions can be aggregated and fed back on the clinical service.

This sequence of analyzing cases of potential diagnostic error has been used by hospital medicine programs, patient safety programs, and other clinical services in multiple health systems.



Culture: Just culture for patient safety is important for using this process to identify systems barriers to diagnosis and to avoid blaming individuals for systems issues.

Usability: Having multiple case reviewers for the SaferDx tool with opportunity for discussion will allow calibration. Generally intuitive for clinicians. Teams will gain effectiveness with root cause analysis process with practice, but most organizations have root cause analysis experts.

Infrastructure: Ideal situation is to embed this work as part of the existing patient safety program where patient safety specialists or risk managers can participate and sustain the review process. Mostly human resource/time is required.

Which stakeholders are essential for the tool to be implemented? Physicians, nurses, and other health professionals who care for patients as well as healthcare quality and risk management professionals would ideally partner to implement this review process.



Cost (human and technical): Mostly human time for review and root cause meetings.

Location of usage (ambulatory vs inpatient): Any site where patients are cared for.

Roll out plan: Can pilot starting with review of one case, start on one clinical service, or make part of institutional patient safety program whenever medical error or harm cases involving diagnosis are all reviewed.


Post-Implementation Status

Current status (partly adopted or widely adopted): Not in widespread use.

Limitations: Some institutions may not have the resources or expertise to sustain case reviews over time. Finding cases to review may be challenging as well.

Outcome measures: Multiple organizations have demonstrated actions taken to reduce risk of diagnostic error after learning from this type of review process. This tool as the potential to uncover vulnerabilities in the diagnostic process in an organization and point to solutions to mitigate these vulnerabilities. The impact on patient outcomes, however, requires more study.

Sustainability/Viability: The SaferDX process was developed and published in 2015. Root cause analysis has been happening in healthcare for several decades and the diagnostic error fishbone tool based on the DEER criteria has been in use since 2013.



Singh H, Sittig DF, Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework, BMJ Quality and Patient Safety 2015; 0:1-8

Davalos MC et al, Finding Diagnostic Errors in Children Admitted to the PICU, Pediatric Critical Care Medicine 2017; 18(3): 265-271

Reilly JB, et al, Use of a novel, modified fishbone diagram to analyze diagnostic errors, Diagnosis 2014; 1(2): 167-71

Share Your Tools

Do you have a practice improvement tool you are using to improve diagnostic quality and safety? Please share it with us at info@improvediagnosis.org.

More on SaferDx

Want to learn more about SaferDx? Check out the open access article published in BMJ Quality & Safety describing the framework.