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 7, 2023.
  1. Grob R. The heart of patient-centered care. J Health Polit Policy Law 2013;38(2):457-465. https://pubmed.ncbi.nlm.nih.gov/23262765/. Accessed June 7, 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 7, 2023.
  1. Dohan D, Garrett SB, Rendle KA, Halley M, Abramson C. The importance of integrating narrative into health care decision making. Health Aff (Millwood) 2016;35(4):720-725. https://pubmed.ncbi.nlm.nih.gov/27044974/. Accessed June 7, 2023.
  1. Gillespie A, Reader TW. Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety. Milbank Q 2018;96(3):530-567. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6131356/. Accessed June 7, 2023.
  1. Grob R, M Schlesinger, 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 7, 2023.
  1. Eldridge N, Wang Y, Metersky M, Eckenrode S, Mathew J, Sonnenfeld N, Perdue-Puli J, Hunt D, Brady PJ, McGann P, Grace E, Rodrick D, Drye E, Krumholz HM. Trends in adverse event rates in hospitalized patients, 2010-2019. JAMA 2022;328(2):173-183. doi:10.1001/jama.2022.9600. Accessed June 7, 2023.
  1. Harrison R, Walton M, Manias E, Smith-Merry J, Kelly P, Iedema R, Robinson L. The missing evidence: a systematic review of patients’ experiences of adverse events in health care. Int J Qual Health Care 2015;27(6):424-442. https://pubmed.ncbi.nlm.nih.gov/26424702/. Accessed June 7, 2023.
  1. Solberg LI, Asche SE, Averbeck BM, Hayek AM, Schmitt KG, Lindquist TC, Carlson RR. Can patient safety be measured by surveys of patient experiences? Jt Comm J Qual Patient Saf 2008;34(5):266-274. https://pubmed.ncbi.nlm.nih.gov/18491690/. Accessed June 7, 2023.
  1. De Brun A, Heavey E, Waring J, Dawson P, Scott J. PReSaFe: a model of barriers and facilitators to patients providing feedback on experiences of safety. Health Expect 2017;20(4):771-778. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5512993/. Accessed June 7, 2023.
  1. Heavey E, Waring J, De Brun A, Dawson P, Scott J. Patients’ conceptualizations of responsibility for healthcare: a typology for understanding differing attributions in the context of patient safety. J Health Soc Behav 2019;60(2):188-203. https://pubmed.ncbi.nlm.nih.gov/31113253/. Accessed June 7, 2023.
  1. Bardach N, Stotts J, Fiore D et al. 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 7, 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 7, 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 7, 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 7, 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 7, 2023.
  1. Bell, SK, Bourgeois F, Dong J, Gillespie A, Ngo LH, Reader TW, Thomas EJ, Desroches CM. Patient identification of diagnostic safety blindspots and participation in ‘good catches’ through shared visit notes. Milbank Q 2022;100(4):1121-1165. https:/pubmed.ncbi.nlm.nih.gov/36539389/. Accessed June 7, 2023.
  1. McDonald KM, Bryce CL, Graber ML. The patient is in: patient involvement strategies for diagnostic error mitigation. BMJ Qual Saf 2013;22(Suppl 2):1825. doi: 10.1136/bmjqs-2012-001623. Accessed June 7, 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 7, 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 7, 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.
  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 7, 2023.
  1. Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med 2013;173(6):418-425. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3690001/. Accessed June 7, 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 7, 2023.
  1. Pinheiro LC, Reshetnyak E, Safford MM, Kern LM. Racial disparities in preventable adverse events attributed to poor care coordination reported in a national study of older U.S. adults. Med Care 2021;59(10):901-906. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8446307/. Accessed June 7, 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 7, 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 7, 2023.
  1. Bell SK, Bourgeois F, DesRoches CM, Dong J, Harcourt K, Liu SK, Lowe E, McGaffigan P, Ngo LH, Novack SA, Ralston JD, Salmi L, Schrandt S, Sheridan S, Sokol-Hessner L, Thomas G, Thomas EJ. Filling a gap in safety metrics: development of a patient-centred framework to identify and categorize patient-reported breakdowns related to the diagnostic process in ambulatory care. BMJ Qual Saf 2022;31:526-540. https://pubmed.ncbi.nlm.nih.gov/34656982/. Accessed June 7, 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 7, 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 7, 2023.
  1. Bardach NS, Lyndon A, Asteria-Peñaloza R, Goldman LE, Lin GL, Dudley RA. From the closest observers of patient care: a thematic analysis of online narrative reviews of hospitals. BMJ Qual Saf 2016 Nov;25(11):889-897. doi: 10.1136/bmjqs-2015-004515. Accessed June 7, 2023.
  1. Fisher KA, Ahmad S, Jackson M, Mazor KM. Surrogate decision makers’ perspectives on preventable breakdowns in care among critically ill patients: a qualitative study.  Patient Educ Couns 2016;99:1685-1693. https://pubmed.ncbi.nlm.nih.gov/27067065/. Accessed June 7, 2023.
  1. Lai AY, Yuan CT, Marsteller JA, Hannum SM, Lasser EC, Heughan JA, Oberlander T, Berger ZD, Gurses AP, Kharrazi H, Pitts SI, Scholle SH, Dy SM. Patient safety in primary care: conceptual meanings to the health care team and patients. J Am Board Fam Med 2020;33(5):754-764. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7938708/. Accessed June 7, 2023.
  1. Zhu J, Stuver SO, Epstein AM, Schneider EC, Weissman JS, Weingart SN. Can we rely on patients’ reports of adverse events? Med Care 2011;49(10):948-955. https://pubmed.ncbi.nlm.nih.gov/21642876/. Accessed June 7, 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 7, 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 7, 2023.
  1. Patient Reported Measures: Potential and Peril for Assessing Diagnostic Excellence (Expert Convening Report, April 28, 2022, available upon request from Johns Hopkins University research team lead, Kathryn M. McDonald).
  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 7, 2023.
  1. Gleason K, McDonald K. In response to Ledford and colleagues Toward a Model of Shared Meaningful Diagnosis: how to capture a shared, meaningful diagnosis? Patient Educ Couns 2020 Aug 28;S0738-3991(20)30461-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914276/. Accessed June 7, 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 7, 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 7, 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 7, 2023.
  1. Southwick FS, Cranley NM, Hallisy JA. A patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families. BMJ Qual Saf 2015;24:620-629. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4602250/. Accessed June 7, 2023.
  1. Rosenthal M, M Schlesinger. 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 7, 2023.
  1. Mazor K, Roblin DW, Greene SM, Fouayzi H, Gallagher TH. Primary care physicians’ willingness to disclose oncology errors involving multiple clinicians to patients. BMJ Qual Saf  2016;25:787-795. https://pubmed.ncbi.nlm.nih.gov/26534996/. Accessed June 7, 2023.
  1. Schlesinger M, Mitchell S, Elbel B. Voices unheard: barriers to the expression of dissatisfaction with health plans. Milbank Q 2002;80(4):709-755. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690133/. Accessed June 7, 2023.
  1. Schlesinger M. The canary in the gemeinshaft: the public voice of patients as a means of enhancing health system performance. In: Hoffman B, Tomes N, Grob R, Schlesinger M, eds. Patients as Policy Actors. New Brunswick, NJ: Rutgers University Press; 2011. p. 148-176.
  1. Suzuki R, Yajima N, Sakurai K, Oguro N, Wakita T, Thom D, Kurita N. Association of patients’ past misdiagnosis experiences with trust in their current physician among Japanese adults. J Gen Intern Med 2022;37(5):1115-1121. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8971208/. Accessed June 7, 2023.
  1. Piccardi C, Detollenaere J, Vanden Bussche P, Willems S. Social disparities in patient safety in primary care: a systematic review. Int J Equity Health 2018;17(1):114. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081855/. Accessed June 7, 2023.
  1. Lin PJ, Daly AT, Olchanski N, Cohen JT, Neumann PJ, Faul JD, Fillit HM, Freund KM. Dementia diagnosis disparities by race and ethnicity. Med Care 2021;59(8):679-686. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263486/. Accessed June 7, 2023.
  1. Britton LE, Hussey JM, Crandell JL, Berry DC, Brooks JL, Bryant AG. Racial/ethnic disparities in diabetes diagnosis and glycemic control among women of reproductive age. J Womens Health (Larchmt) 2018;27(10):1271-1277. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6205045/. Accessed June 7, 2023.
  1. Moy E, Barrett M, Coffey R, Hines AL, Newman-Toker DE. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics. Diagnosis (Berl) 2015;2(1):29-40. https://pubmed.ncbi.nlm.nih.gov/29540019/. Accessed June 7, 2023.
  1. McDonald KM. Achieving equity in diagnostic excellence. JAMA 2022;327(20):1955-1956. https://doi.org/10.1001/jama.2022.7252. Accessed June 7, 2023.
  1. Smith C. First, do no harm: institutional betrayal and trust in health care organizations. J Multidiscip Healthc 2017:10 133-144. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5388348/. Accessed June 7, 2023.
  1. Krakower T. To err is human, to apologize is hard. JAMA 2021;326(3):223-224. doi: 10.1001/jama.2021.10840. Accessed June 7, 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-vol1-references.html

Click to copy citation