Diagnostic errors are both frequent and harmful, accounting for the most common potentially preventable cause of serious disability and death identified in malpractice cases.1 We do not have systematic and rigorous ways to define and enumerate diagnostic errors, but we are often reminded by patients and clinicians of the harm from missed opportunities to intervene to optimize outcomes. The 2015 National Academy of Medicine report Improving Diagnosis in Health Care declared the need to improve diagnosis as a “moral and professional imperative.”2 However, solutions are not easy or clear.
Despite growing awareness of diagnostic error, most healthcare systems do not track or record diagnostic quality, and many diagnostic safety events are not recognized. Without methods to identify, measure, investigate, and analyze events, healthcare organizations cannot understand causes of diagnostic errors, identify contributing factors, or create solutions. A learning health system relies on such information to act.
One of the best ways to collect information about diagnostic errors is through self-reporting by patients and clinicians. Successful approaches to learn from diagnostic quality and develop strategies to reduce harm from diagnostic failure depend on two workplace characteristics: psychological safety and organizational safety culture. Both concepts are explored in this issue brief.
