U.S. flag

An official website of the Department of Health and Human Services

SHARE:

FacebookXEmail AHRQPrintShare
Diagnostic Safety and Quality

Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors

References

  1. Schlesinger, M. Choice cuts: parsing policymakers’ pursuit of patient empowerment from an individual perspective. J Health Econ Policy Law 2010;5(3):365-387. https://pubmed.ncbi.nlm.nih.gov/20602858/. Accessed June 9, 2023.
  1. Grob R. The heart of patient-centered care. J Health Polit Policy 2013;38(2):457-465. https://pubmed.ncbi.nlm.nih.gov/23262765/. Accessed June 9, 2023.
  1. Giardina TD, Haskell H, Menon S, Hallisy J, Southwick FS, Sarkar U, Royse KE, Singh H. Learning from patients’ experiences related to diagnostic errors is essential for progress in patient safety. Health Aff (Millwood) 2018;37(11):1821-1827. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103734/. Accessed June 9, 2023.
  1. 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. https://www.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science.html. Accessed June 9, 2023.
  1. McGlynn E, McDonald K, Cassel C. Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the Institute of Medicine. JAMA 2015;314(23):2501-2502. doi: 10.1001/jama.2015.13453. Accessed June 9, 2023.
  1. Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. Final Report. (Funded by the Centers for Medicare & Medicaid Services under Contract No. HHSM-500-2017-00060I–75FCMC19F0005.) Washington DC: National Quality Forum; November 2020. https://www.qualityforum.org/Publications/2020/10/Reducing_Diagnostic_Error__Measurement_Considerations_-_Final_Report.aspx. Accessed June 9, 2023.
  1. Schlesinger M, Grob R, Shaller D, Martino SC, Parker AM, Finucane ML, Cerully JL, Rybowski L, Taking patients’ narratives about clinicians from anecdote to science. New Engl J Med 2015;373(7):675-679. https://www.nejm.org/doi/10.1056/NEJMsb1502361. Accessed June 9, 2023.
  1. Bardach N, Stotts J, Fiore D, Sarkar U, Sharma AE, Boscardin WJ, Avina L, Peralta-Neel C, Rosenbluth G. Family Input for Quality and Safety (FIQS): Using mobile technology for in-hospital reporting from families and patients. J Hosp Med 2022; doi: 10.1002/jhm.2777. Accessed June 9, 2023.
  1. Khan A, Coffey M, Litterer K, et al. Families as partners in hospital error and adverse event surveillance. JAMA Pediatr 2017;171(4):372-381. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5526631/. Accessed June 9, 2023.
  1. Weingart SN, Weissman JS, Zimmer KP, Giannini RC, Quigley DD, Hunter LE, Ridgely MS, Schneider EC. Implementation and evaluation of a prototype consumer reporting system for patient safety events. Int J Qual Health Care 2017 Aug 1;29(4):521-526. https://pubmed.ncbi.nlm.nih.gov/28541430/. Accessed June 9, 2023.
  1. Hernan A, Giles S, Fuller J, Johnson JK, Walker C, Dunbar JA. Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative study. BMJ Qual Saf 2015;24:583-593. https://pubmed.ncbi.nlm.nih.gov/25972223/. Accessed June 9, 2023.
  1. Earl T, Katapodis N, Schneiderman S. Care transitions. In: Hall KK, Shoemaker-Hunt S, Hoffman L, Richard S, Gall E, Schoyer E, Costar D, Gale B, Schiff G, Miller K, Earl T, Katapodis N, Sheedy C, Wyant B, Bacon O, Hassol A, Schneiderman S, Woo M, LeRoy L, Fitall E, Long A, Holmes A, Riggs J, Lim A. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF. https://www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/index.html. Accessed June 9, 2023.
  1. Grob R, Schlesinger M, Shaller D, Parker A, Barre LR, Martino S, Finucane M, Rybowski L, Cerully J. Breaking narrative ground: innovative methods for rigorously eliciting and assessing patient narratives. Health Serv Res 2016 Jun;51(Suppl 1):1248-1272. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4874935/. Accessed June 9, 2023.
  1. Schlesinger M, Grob R, Shaller D, Martino SC, Parker AM, Rybowski L, Finucane ML, Cerully JL. A rigorous approach to large-scale elicitation and analysis of patient narratives. Med Care Res Rev 2020 Oct;77(5):416-427. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731154/. Accessed June 9, 2023.
  1. Blendon R, Desroches B, Brodie M, Benson JM, Rosen AB, Schneider E, Altman DE, Zapert K, Herrmann MJ, Steffenson AE. Views of practicing physicians and the public on medical errors. New Engl J Med 2002;347:1933-1940. https://www.nejm.org/doi/10.1056/NEJMsa022151. Accessed June 9, 2023.
  1. NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute. Americans’ Experiences With Medical Errors and Views on Patient Safety. Cambridge, MA: Institute for Healthcare Improvement and NORC at the University of Chicago; 2017. https://www.ihi.org/about/news/Documents/ IHI_NPSF_NORC_Patient_Safety_Survey_2017_Final_Report.pdf. Accessed June 9, 2023.
  1. Rosenthal M, Schlesinger M. Not afraid to blame: the neglected role of blame attribution in medical consumerism and some implications for health policy. Milbank Q 2002;80(1):41-95. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690101/. Accessed June 9, 2023.
  1. O’Hara JK, Reynolds C, Moore S, Armitage G, Sheard L, Marsh C, Watt I, Wright J, Lawton R. What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study. BMJ Qual Saf 2018;27:673-682. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109253/. Accessed June 9, 2023.
  1. Weissman JS, Schneider EC, Weingart SN, Epstein AM, David-Kasdan J, Feibelmann S, Annas CL, Ridley N, Kirle L, Gatsonis C. Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not? Ann Intern Med 2008;149:100-108. https://pubmed.ncbi.nlm.nih.gov/18626049/. Accessed June 9, 2023.
  1. Hillman KM, Lilford R, Braithwaite J. Patient safety and rapid response systems. Med J Aust 2014;201(11):654-656. https://pubmed.ncbi.nlm.nih.gov/25495310/. Accessed June 9, 2023.
  1. Ricci-Cabello I, Avery AJ, Reeves D, Kadam UT, Valderas JM. Measuring patient safety in primary care: the development and validation of the “patient reported experiences and outcomes of safety in primary care” (PREOS-PC). Ann Fam Med 2016;14:253-261. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868564/. Accessed June 9, 2023.
  1. Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, Bower P, Campbell S, Haneef R, Avery AJ, Ashcroft DM. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ 2019 Jul 17:366:l4185. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6939648/. Accessed June 9, 2023.
  1. Kenward L. Understanding and responding to severe and enduring patient distress resulting from episodes of healthcare. Nurs Stand 2017;31(31):54-63. https://pubmed.ncbi.nlm.nih.gov/28351257/. Accessed June 9, 2023.
  1. Birks Y, Harrison R, Bosanquet K, Hall J, Harden M, Entwistle V, Watt I, Walsh P, Ronaldson S, Roberts D, Adamson J, Wright J, Iedema R. An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration. Southampton, UK: NIHR Journals Library 2014;Jul. https://pubmed.ncbi.nlm.nih.gov/25642494/. Accessed June 9, 2023.
  1. Prentice JC, Bell SK, Thomas EJ, Schneider EC, Weingart SN, Weissman JS, Schlesinger MJ. Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey. BMJ Qual Saf. 2020;29(11):883-894. https://pubmed.ncbi.nlm.nih.gov/31959717/. Accessed June 9, 2023.
  1. Ottosen MJ, Sedlock EW, Aigbe AO, Bell SK, Gallagher TH, Thomas EJ. Long-term impacts faced by patients and families after harmful healthcare events. J Patient Saf 2021 Dec 1;17(8):e1145-e1151. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6050155/. Accessed June 9, 2023.
  1. Moore J; Bismark M; Mello MM. Patients’ experiences with communication-and-resolution programs after medical injury. JAMA Intern Med 2017;177(11):1595-1603. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710270/. Accessed June 9, 2023.
  1. Mazor KM, Greene SM, Roblin D, Lemay CA, Firneno CL, Calvi J, Prouty CD, Horner K, Gallagher TH. More than words: patients’ views on apology and disclosure when things go wrong in cancer care. Patient Educ Couns 2013;90(3):341-346. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3214230/. Accessed June 9, 2023.
  1. Harvard School of Public Health. The Public’s Views on Medical Error in Massachusetts. Boston, MA: Betsy Lehman Center for Patient Safety and Health Policy Commission; 2014. https://www.hsph.harvard.edu/wp-content/uploads/sites/21/2014/12/Patient-Safety-Report-12-14.pdf. Accessed June 9, 2023.
  1. Birkeland S. Health care complaints and adverse events as a means of user involvement for quality and safety improvement. Milbank Q 2019;97(1):346-349. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422599/. Accessed June 9, 2023.
  1. Sacco AY, Self QR, Worswick EL, Couperus CJ, Kolli SS, Muñoz SA, Carney JK, Repp AB. Patients’ perspectives of diagnostic error: a qualitative study. J Patient Saf 2020;17(8):e1759-1764. https://pubmed.ncbi.nlm.nih.gov/32168272/. Accessed June 9, 2023.
  1. Kistler CE, Walter LC, Mitchell CM, Sloane PD. Patient perceptions of mistakes in ambulatory care. Arch Intern Med 2010;170:1480-1487. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3070906/. Accessed June 9, 2023.
  1. Horwitz L, Moriarty J, Chen C, Fogerty RL, Brewster UC, Kanade S, Ziaeian B, Jenq GY, Krumholz HM. Quality of discharge practices and patient understanding at an academic medical center. JAMA Intern Med 2013:73(18):1715-1722. doi: 10.1001/jamainternmed.2013.9318. Accessed June 9, 2023.
  1. Grob R, Schlesinger M, Barre LR, Bardach N, Lagu T, Shaller D, Parker AM, Martino SC, Finucane ML, Cerully JL, Palimaru A. What words convey: the potential for patient narratives to inform quality improvement. Milbank Q 2019;97(1):176-227. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422610/. Accessed June 9, 2023. Accessed June 9, 2023.
  1. Cassel C, T Fulmer. Achieving diagnostic excellence for older patients. JAMA 2022 Mar 8;327(10):919-920. https://pubmed.ncbi.nlm.nih.gov/35175301/. Accessed June 9, 2023.
  1. LaDonna KA Watling CJ, Cristancho SM, Burm D. Exploring patients’ and physicians’ perspectives about competent health advocacy. Med Educ 2021 Apr;55(4):486-495. https://pubmed.ncbi.nlm.nih.gov/33152148/. Accessed June 9, 2023.
  1. Schlesinger M, Shaller D, Grob R. Using patient reported information to improve clinical practice. Health Serv Res 2015 Dec;50(Suppl 2):2116-2154. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5115180/. Accessed June 9, 2023.
Page last reviewed June 2023
Page originally created June 2023

Internet Citation: References. Content last reviewed June 2023. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-references.html

Click to copy citation