AHRQ Papers on Diagnostic Safety Topics

Diagnostic errors occur in all settings of care, contribute to about 10 percent of patient deaths, and are the primary reason for medical liability claims. As the lead Federal agency investing in research to improve diagnostic safety and reduce diagnostic error, AHRQ is currently developing a series of papers on different diagnostic safety issues. Some of these will be released as Issue Briefs on the AHRQ website, while others will be published in peer-reviewed journals. A list of topics is below.

Issue Briefs

• Diagnostic Excellence in U.S. Rural Healthcare: A Call to Action (PDF, 2.3 MB)
• The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design (PDF, 1.3 MB)
• State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults (PDF, 1.2 MB)
• Diagnostic Stewardship as a Model To Improve the Quality and Safety of Diagnosis
• Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study
• Electronic Test Result Communication in the Era of the 21st Century Cures Act
• Documenting Diagnosis: Exploring the Impact of Electronic Health Records on Diagnostic Safety (PDF, 1.5 MB)
• Cognitive Load Theory and Its Impact on Diagnostic Accuracy (PDF, 1.2 MB)  
• Current State of Diagnostic Safety: Implications for Research, Practice, and Policy (PDF, 1.4 MB)
• Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error (PDF, 1 MB)
• Pediatric Diagnostic Safety: State of the Science and Future Directions (PDF, 1.5 MB)
• Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety (PDF, 1.7 MB)
• Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors. Volume 1: Why Patient Narratives Matter (PDF, 1 MB)
• Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors. Volume 2: Eliciting Patient Narratives (PDF, 1 MB)
• Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action (PDF, 2 MB)
• Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators (PDF, 1.2 MB)
• Improved Diagnostic Accuracy Through Probability-Based Diagnosis (PDF, 976 KB)
• Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department  (PDF, 1.5 MB)
• Improving Education—A Key to Better Diagnostic Outcomes (PDF, 2 MB)
• The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science (PDF, 1.4 MB).
• Leadership To Improve Diagnosis: A Call to Action (PDF, 2.3 MB).
• Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments (PDF, 3 MB)
• Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction (PDF, 971 KB).
• Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis (PDF, 1 MB).
• Operational Measurement of Diagnostic Safety: State of the Science (PDF, 2 MB).

Journal Articles

• The PRIDx framework to engage payers in reducing diagnostic errors in health care (PDF, 1.3 MB).
• Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda (PDF, 289 KB).
• Advancing Diagnostic Equity Through Clinician Engagement, Community Partnerships, and Connected Care (PDF, 204 KB).
• Defining diagnostic error: a scoping review to assess the impact of the national academies' report improving diagnosis in health care (PDF, 1 MB).
• Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events (PDF, 1 MB).
• Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes (PDF, 726 KB).