Findings and recommendations are informed by a rapid narrative review and interviews with nine diagnostic safety experts, representing one or more of the following areas: cognitive psychology, social sciences, informatics, clinical medicine, medical education, patient engagement, and implementation. The experts provided feedback on both the methodological approach and initial content, and their input was used to clarify findings or enhance interpretation.
2.1. Rapid Narrative Review
We first convened a team of eight people, including two with extensive expertise and knowledge in diagnostic safety (coauthors Sittig and Singh) and six literature reviewers (coauthors Khan, Cholankeril, Sloane, Bradford, Matin, and Ramisetty). The initial review involved a broad literature search and examination of various reputable sources, including:
- AHRQ’s Patient Safety Network and grants website.14,16,17
- National Academy of Medicine (NAM) Diagnostic Excellence Scholars website.18
- NAM reports.12
- Society to Improve Diagnosis in Medicine (SIDM) Foundational Readings in Diagnostic Error and Fellows pages.19,20
- PubMed (search terms are included in Appendix A).
From this initial review, we developed 10 domains (Figure 1) that broadly represented the main areas of diagnostic safety work, which could then be used to identify gaps in the scientific literature. These 10 domains constituted a pragmatic framework to examine the current state of science and gaps.
Based on the initial review, we created subdomains within each domain to facilitate a more comprehensive review of the literature and to help synthesize findings. For the comprehensive review, we evaluated published literature, grey literature, web-based resources and tools, and ongoing projects related to diagnostic safety, focusing on sources published between 2013 and 2023. While a large volume of foundational work was conducted before this period, we focused on more recent literature that was not included in NASEM’s 2015 landmark report.
Figure 1. Operational framework to understand the state of the science of diagnostic safety
2.2. Qualitative Methods
Qualitative interviews with nine experts in the field of diagnostic safety helped ensure the adequacy and appropriateness of the scope and coverage of the 10 domains (Appendix B includes names of external experts). Before the interviews, each expert was provided with an initial outline of the domains to ensure time for reflection and feedback.
We developed a semistructured open-ended interview guide with probes focused on each of the 10 domains. We designed this guide to ensure adequacy of domains and subdomains, identify any gaps not highlighted in our findings, and determine how to address some of the existing gaps we found in each domain. We asked supplemental questions on potential recommendations to promote broad-scale improvement in diagnostic safety.
Two of the coauthors (Khan and Shahid) conducted the interviews remotely via video conference between May and June 2023. Participants were recruited through purposive sampling. Each interview lasted approximately 60 minutes, and participants consented to audio recording (Appendix C includes the interview guide).
Interviews were transcribed through a third-party transcription service and subsequently de-identified to maintain confidentiality. A qualitative methodologist conducted a rapid content analysis of interview transcripts to gain an initial understanding of the content. Rapid content analysis provides valuable initial insights and can be an effective option when it is necessary to quickly identify essential trends to inform further research. Each transcript was reviewed to organize the data of participant’s feedback and specific suggestions for improvement.
