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Diagnostic Safety and Quality

Leadership To Improve Diagnosis: A Call to Action

References

  1. Phillips RL, Bartholomew LA, Dovey SM, Fryer GE Jr, Miyoshi TJ, Green LA. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Heal Care. 2004;13:121-26. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743812/. Accessed June 3, 2021.
  2. Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care. Balogh EP, Miller, BT, Ball JR., eds. Washington, DC: National Academies Press; 2015. https://www.ncbi.nlm.nih.gov/books/NBK338596/. Accessed June 3, 2021.
  3. Shepard J, Frederick J, Wong F, Madison S, Tompkins L, Hadhazy E. Could the prevention of health care–associated infections increase hospital cost? The financial impact of health care–associated infections from a hospital management perspective. Am J Infect Control. 2020 Mar;48(3):255-60. https://pubmed.ncbi.nlm.nih.gov/32089192/. Accessed June 3, 2021.
  4. Patient Safety Watchdog The Leapfrog Group Funded for National Initiative on Preventing Harm From Diagnostic Error. https://www.leapfroggroup.org/news-events/patient-safety-watchdog-leapfrog-group-funded-national-initiative-preventing-harm. Accessed June 3, 2021.
  5. Singh H, Bradford A, Goeschel C. Operational Measurement of Diagnostic Safety: State of the Science. Rockville, MD: Agency for Healthcare Research and Quality; 2020. AHRQ Publication No. 20-0040-1-EF. https://www.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science.html. Accessed June 3, 2021.
  6. Society to Improve Diagnosis in Medicine. https://www.improvediagnosis.org/. Accessed June 3, 2021.
  7. Dweck C. What Having a “Growth Mindset” Actually Means. Harv Bus Rev. 2016;13:213-26. https://hbr.org/2016/01/what-having-a-growth-mindset-actually-means.
  8. Institute of Medicine Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS. eds. Washington, DC: National Academies Press; 1999. https://www.ncbi.nlm.nih.gov/books/NBK225182/. Accessed June 3, 2021.
  9. Safer Together: A National Action Plan to Advance Patient Safety. Rockville, MD: Agency for Healthcare Research and Quality; 2020. https://www.ahrq.gov/patient-safety/reports/safer-together.html. Accessed June 3, 2021.
  10. About Learning Health Systems. Rockville, MD: Agency for Healthcare Research and Quality; 2019. https://www.ahrq.gov/learning-health-systems/about.html. Accessed June 3, 2021.
  11. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. https://www.ncbi.nlm.nih.gov/books/NBK222274/. Accessed June 3, 2021.
  12. Obenrader C, Broome ME, Yap TL, Jamison F. Changing team member perceptions by implementing TeamSTEPPS® in an emergency department. J Emerg Nurs. 2019;45(1):31-7. https://pubmed.ncbi.nlm.nih.gov/30322675/. Accessed June 3, 2021.
  13. Waters HR, Korn R, Colantuoni E, Berenholtz SM, Goeschel CA, Needham DM, Pham JC, Lipitz-Snyderman A, Watson SR, Posa P, Pronovost PJ. The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs. Am J Med Qual. 2011;26(5):333-9. https://pubmed.ncbi.nlm.nih.gov/21856956/. Accessed June 3, 2021.
  14. Marsteller JA, Bryan Sexton J, Hsu YJ, Hsiao CJ, Holzmueller CG, Pronovost PJ, Thompson DA. A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units. Crit Care Med. 2012;40(11):2933-9. https://pubmed.ncbi.nlm.nih.gov/22890251/. Accessed June 3, 2021.
  15. Allegranzi B, Aiken AM, Zeynep Kubilay N, Nthumba P, Barasa J, Okumu G, Mugarura R, Elobu A, Jombwe J, Maimbo M, Musowoya J, Gayet-Ageron A, Berenholtz SM. A multimodal infection control and patient safety intervention to reduce surgical site infections in Africa: a multicentre, before–after, cohort study. Lancet Infect Dis. 2018;18(5):507-15. PMID: 29519766. https://pubmed.ncbi.nlm.nih.gov/29519766/. Accessed June 3, 2021.
  16. Zafar MA, Panos RJ, Ko J, Otten LC, Gentene A, Guido M, Clark K, Lee C, Robertson J, Alessandrini EA. Reliable adherence to a COPD care bundle mitigates system-level failures and reduces COPD readmissions: a system redesign using improvement science. BMJ Qual Saf. 2017;26(11):908-18. https://pubmed.ncbi.nlm.nih.gov/28733370/. Accessed June 3, 2021.
  17. Braithwaite J, Mannion R, Matsuyama Y, Shekelle P, Whittaker S, Al-Adawi S. Health Systems Improvement Across the Globe: Success Stories From 60 Countries. 1st ed. London: Taylor & Francis; 2018.
  18. Sandberg KC. Leadership in quality improvement. Curr Probl Pediatr Adolesc Health Care. 2018;48(8):206-10. https://pubmed.ncbi.nlm.nih.gov/30270133/. Accessed June 3, 2021.
  19. Russell JA, Leming-Lee TS, Watters R. Implementation of a nurse-driven CAUTI prevention algorithm. Nurs Clin North Am. 2019;54(1):81-96. https://pubmed.ncbi.nlm.nih.gov/30712546/. Accessed June 3, 2021.
  20. Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf. 2015;24(2):103-10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4316850/. Accessed June 3, 2021.
  21. Dweck CS. Mindset: The New Psychology of Success .1st ed. New York: Random House Publishing; 2006.
  22. McFadden KL, Stock GN, Gowen CR 3rd. Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety. Health Care Manage Rev. 2015;40(1):24-34. https://pubmed.ncbi.nlm.nih.gov/24566246/. Accessed June 3, 2021.
  23. Singh H, Upadhyay DK, Torretti D. Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan. Acad Med. 2020;95:1172-78. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402609/. Accessed June 3, 2021.
  24. Heath C, Staudenmayer N. Coordination neglect: how lay theories of organizing complicate coordination in organizations. Res Organ Behav. 2000;22:153-91. https://doi.org/10.1016/S0191-3085(00)22005-4. Accessed June 3, 2021.
  25. Keroack MA, Youngberg BJ, Cerese JL, Krsek C, Prellwitz L, Trevelyan EW. Organizational factors associated with high performance in quality and safety in academic medical centers. Acad Med. 2007;82(12):1178-86. https://pubmed.ncbi.nlm.nih.gov/18046123/. Accessed June 3, 2021.
  26. Newman-Toker DE, Schaffer AC, Yu-Moe CW, Nassery N, Saber Tehrani AS, Clemens GD, Wang Z, Zhu Y, Fanai M, Siegal D. Serious misdiagnosis-related harms in malpractice claims: the “Big Three” – vascular events, infections, and cancers. Diagnosis. 2019;6(3):227-40. https://pubmed.ncbi.nlm.nih.gov/31535832/. Accessed June 3, 2021.
  27. Committee on the Learning Health Care System in America; Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Washington, DC: National Academies Press; 2013. https://www.ncbi.nlm.nih.gov/books/NBK207225/. Accessed June 3, 2021.
  28. Brach C, Keller D, Hernandez LM, Baur C, Parker R, Dreyer B, Schyve P, Lemerise AJ, Schillinger D. Ten Attributes of Health Literate Health Care Organizations. Discussion Paper. Washington, DC: National Academy of Medicine; 2012. https://doi.org/10.31478/201206a. Accessed June 3, 2021.
  29. About SDOH in Healthcare. Rockville, MD: Agency for Healthcare Research and Quality; 2020. https://www.ahrq.gov/sdoh/about.html. Accessed June 3, 2021.
  30. Austin JM, Weeks K, Pronovost PJ. Health system leaders’ role in addressing racism: time to prioritize eliminating health care disparities. Jt Comm J Qual Patient Saf. 2021;47(4):265-7. PMID: 33339750.
  31. Hall LH, Johnson J, Watt I, Tsipa A, O’Connor DB. Healthcare staff wellbeing, burnout, and patient safety: a systematic review. PLoS One. 2016 Jul 8;11(7):e0159015. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0159015. Accessed June 3, 2021.
  32. Feussner JR, Oddone EZ, Eugene CR. “To improve is to change”: improving U.S. healthcare. Am J Med Sci. 2016 Jan;351(1):1-2. PMID: 26802751.
Page last reviewed June 2021
Page originally created June 2021

Internet Citation: References. Content last reviewed June 2021. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-6.html

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