In the Spirit of Patient Safety Awareness Week, AHRQ Sharpens Its Focus on Diagnostic Safety

In 2023, the American healthcare system remains too often flawed by fragmentation in care, with a lack of communication between clinicians and patients and poor coordination within clinical teams. The result can be missed opportunities that jeopardize care, sometimes with tragic consequences.

These stubborn gaps in care, heightened by misaligned financial and regulatory incentives, have contributed to the lackluster performance of our healthcare system. As shown in AHRQ’s most recent National Healthcare Quality and Disparities Report, we are stewards of a disjointed system that often fails to provide safe, high-quality care, particularly for underserved communities.

Such complex challenges can only be addressed once we agree to work on solutions together. My colleagues and I were gratified when so many public- and private-sector healthcare leaders gathered at the end of 2022 for a meeting convened by Department of Health and Human Services (HHS) Secretary Xavier Becerra to discuss how we can all recommit to patient and workforce safety after the stresses and strains that the pandemic placed on our healthcare systems. Participants expressed strong interest in co-creating The National Action Alliance to Advance Patient Safety that Secretary Becerra charged the Department to spearhead.

And now, as we begin another Patient Safety Awareness Week, AHRQ is pleased to highlight the vital work we’re pursuing to fortify our commitment and add to the growing momentum to advance safe, high-quality care for all patients.

Last month, AHRQ issued a Notice of Funding Opportunity that signaled the Agency’s focus on improving diagnostic safety. Understanding and Improving Diagnostic Safety in Ambulatory Care: Incidence and Contributing Factors (R01) invites research proposals to help us better understand and enhance diagnostic safety in the heterogenous ambulatory care environment. Researchers are encouraged to investigate the incidence of diagnostic errors and their causes, and findings may be used to design and perform testing involving patient safety interventions.

In tandem with that initiative, AHRQ issued Improving Diagnostic Safety in Ambulatory Care: Strategies and Interventions (R18). In this Notice of Funding Opportunity, AHRQ invites proposals focused on research demonstrating and disseminating diagnostic safety in ambulatory care. Demonstration projects may be conducted to show the effectiveness of an existing or new approach, such as a feedback process, or the effectiveness of a technology-based application, such as a new computer algorithm, to improve diagnostic accuracy.

While eagerly awaiting the best ideas from those solicitations, we’re excited to follow the progress unfolding among our Diagnostic Safety Centers of Excellence. Funding approved by Congress in 2022 allowed AHRQ to fund the work of grantees now investigating a wide range of topics:

• Several investigators are directly seeking the wisdom and insights of patients and patient representatives. Some are working with patients to co-design patient-centered solutions. Patients with limited English proficiency and elderly patients with chronic illnesses are receiving special attention.
• Other projects explore the challenges and opportunities that electronic health records (EHRs) present. These efforts aim to leverage the vast amounts of data stored in EHRs, and the potential to improve the display of the information in EHRs, to facilitate diagnosis.
• Several investigative teams seek to improve the diagnosis of specific medical conditions, such as cancer, stroke, sepsis, hypertension, and unexplained weight loss. Each condition can potentially increase morbidity or mortality if the correct diagnosis is delayed, and investigators are developing ways to improve diagnostic accuracy and timeliness.
• Strategies to improve communication, teamwork, and healthcare delivery processes are also being studied. These processes–effective or not–are ubiquitous and inherently integrated into patient care efforts, and improving them can mean safer care.

Patient Safety Awareness Week has a particular resonance for AHRQ. It is a time to assess our progress, consider new ideas, and applaud successes.  It is a time for honest conversations about the challenges and how the Federal government, industry, patients, and healthcare providers can work together to solve them. Most of all, it is a reminder that providing the safest healthcare possible is a moral imperative.

Dr. Valdez is Director of AHRQ.

Get more AHRQ news, sign up for AHRQ news via email and follow AHRQ on Twitter, LinkedIn, Facebook, and YouTube.