Hardeep Singh

• MD, MPH
• Professor at Baylor College of Medicine and Michael E. DeBakey VA Medical Center

Recently there have been several high-profile ransomware attacks involving hospitals around the world. Ransomware is intended to damage or disable a user’s computer unless the user makes a payment. Once the attack has been launched, users have three options: 1) try to restore their data from backup; 2) pay the ransom; or 3) lose their data. In this...

Objectives There is limited knowledge on how providers and patients in the emergency department (ED) use electronic health records (EHRs) to facilitate the diagnostic process. While EHRs can support diagnostic decision-making, EHR features that are not user-centered may increase the likelihood of diagnostic error. We aimed to identify how EHRs faci...

The Safety Assurance Factors for Electronic Health Record (EHR) Resilience (SAFER) Guides provide recommendations to healthcare organizations for conducting proactive self-assessments of the safety and effectiveness of their EHR implementation and use. Originally released in 2014, they were last updated in 2016. In 2022, the Centers for Medicare an...

Background Emergency departments (EDs) are high-pressure environments where clinicians diagnose patients under significant constraints, including limited medical histories, severe time pressures, and frequent interruptions. Current ED care practices often inadequately support meaningful patient participation. Most interventions prioritize clinical...

Objectives We applied three electronic triggers to study frequency and contributory factors of missed opportunities for improving diagnosis (MOIDs) in pediatric emergency departments (EDs): return visits within 10 days resulting in admission (Trigger 1), care escalation within 24 h of ED presentation (Trigger 2), and death within 24 h of ED visit (...

Background Colorectal cancer (CRC) diagnoses are frequently made through emergency presentations (EPs), a new cancer diagnosis following an emergency care episode or unplanned inpatient admission. The extent and implications of EPs are not well known in the Veterans Affairs (VA) health system, where robust CRC screening protocols exist. The impact...

Importance Missed diagnosis can lead to preventable patient harm. Objective To develop and implement a portfolio of electronic triggers (e-triggers) and examine their performance for identifying missed opportunities in diagnosis (MODs) in emergency departments (EDs). Design, Setting, and Participants In this retrospective medical record review st...

Nearly a decade after the National Academy of Medicine released the “Improving Diagnosis in Health Care” report, diagnostic errors remain common, often leading to physical, psychological, emotional, and financial harm. Despite a robust body of research on potential solutions and next steps, the translation of these efforts to patient care has been...

This Viewpoint provides recommendations for health care organizations (HCOs) and clinicians to facilitate the use of artificial intelligence (AI)–enabled systems, including electronic health records with AI features, in routine clinical care and provides pragmatic guidance for HCOs and clinicians at all stages of AI implementation.

Objectives This study aimed to identify the prevalence of and factors associated with diagnostic uncertainty when critically ill children are admitted to the PICU. Understanding diagnostic uncertainty is necessary to develop effective strategies to reduce diagnostic errors in the PICU. Design Multicenter retrospective cohort study with structured...

BACKGROUND In the Emergency Department (ED), healthcare providers face extraordinary pressures in delivering accurate diagnoses and care, often working with fragmented or inaccessible patient histories while managing severe time constraints and constant interruptions. These challenges and pressures may lead to potential errors in the ED diagnostic...

Background In the emergency department (ED), health care providers face extraordinary pressures in delivering accurate diagnoses and care, often working with fragmented or inaccessible patient histories while managing severe time constraints and constant interruptions. These challenges and pressures may lead to potential errors in the ED diagnostic...

Background The UK National Institute for Health and Care (NICE) recommends that GPs inform patients referred onto the Urgent Suspected Cancer (USC) pathway about what to expect from the service. However, there is a lack of evidence on patient experience and information needs at the point of referral. It is a challenge for GPs to communicate the rea...

This Viewpoint discusses how health information technology (IT) and artificial intelligence (AI) can be used to transform patient safety.

Several strategies have been developed to detect diagnostic errors for organizational learning and improvement. However, few health care organizations (HCOs) have integrated these strategies into routine operations. To address this gap, the Agency for Healthcare Research and Quality released “Measure Dx: A Resource To Identify, Analyze, and Learn F...

Cancer will affect more than one in three U.S. residents in their lifetime, and although the diagnosis will be made efficiently in most of these cases, roughly one in five patients will experience a delayed or missed diagnosis. In this integrative review, we focus on missed opportunities in the diagnosis of breast, lung, and colorectal cancer in th...

Objectives Missed and delayed cancer diagnoses are common, harmful, and often preventable. We previously validated a digital quality measure (dQM) of emergency presentation (EP) of lung cancer in 2 US health systems. This study aimed to apply the dQM to a new national electronic health record (EHR) database and examine demographic associations. Ma...

Background Online records access, including test results, was rolled out as part of changes to the GP contract in England in 2023. Blood test result communication is important for patient-centred care, patient safety, and primary care workload. Evidence is needed to ensure that test results are communicated safely and efficiently to patients in pri...

Importance Missed test results, defined as test results not followed up within an appropriate time frame, are common and lead to delays in diagnosis and treatment. Objective To evaluate the effect of a quality improvement collaborative, the Virtual Breakthrough Series (VBTS), on the follow-up rate of 2 types of test results prone to being missed:...

This Viewpoint proposes a comprehensive sociotechnical approach spanning the entire plastics life cycle to reduce plastic use and pollution in health care.

Up to 33% of American adults will experience a diagnosable anxiety disorder in their lifetime. Approximately one-third of anxiety diagnoses assigned by mental health providers in outpatient settings are unspecified. The tendency of many providers to use an unspecified anxiety diagnosis may negatively impact the provision of evidence-based treatment...

The 21st Century Cures Act enables patients to access their medical records, thus providing a unique opportunity to engage patients in their diagnostic journey. To explore the concordance between patients’ self-reported diagnostic concerns and clinician-interpreted information in their electronic health records. We conducted a mixed-methods analysi...

This cohort study examines whether machine learning (ML) can enhance the ability of electronic triggers to identify possible missed opportunities in diagnosis.

Background Diagnostic errors are a leading cause of patient harm. In 2022, the Leapfrog Group published a report containing 29 evidence‐based practices that hospitals can adopt to reduce diagnostic errors. Objectives To understand the extent to which US hospitals have already implemented these practices, we conducted a national pilot survey of Lea...

Background Managing diagnostic uncertainty is a major challenge in primary care due to factors such as the absence of definitive tests, variable symptom presentations and disease evolution. Maintaining patient trust during a period of investigative uncertainty, whilst minimising scope for diagnostic error is a challenge. Mismanagement can lead to d...

Background: Evidence-based practice in community-acquired pneumonia often assumes an accurate initial diagnosis. Objective: To examine the evolution of pneumonia diagnoses among patients hospitalized from the emergency department (ED). Design: Retrospective nationwide cohort. Setting: 118 U.S. Veterans Affairs medical centers. Patients: Ag...

BACKGROUND Emergency departments (EDs) are high-pressure environments where a diagnosis is made in a resource-constrained context. These environments also require complicated interactions between patients, caregivers, and healthcare providers to make timely diagnoses. EDs, in consequence, predispose to suboptimal diagnostic outcomes, leading to pot...

PURPOSE Missed and delayed cancer diagnoses are common, harmful, and often preventable. Automated measures of quality of cancer diagnosis are lacking but could identify gaps and guide interventions. We developed and implemented a digital quality measure (dQM) of cancer emergency presentation (EP) using electronic health record databases of two heal...

Diagnostic errors are associated with patient harm and suboptimal outcomes. Despite national scientific efforts to advance definition, measurement and interventions for diagnostic error, diagnosis in mental health is not well represented in this ongoing work. We aimed to summarise the current state of research on diagnostic errors in mental health...

Introduction The COVID-19 pandemic advanced the use of telehealth-facilitated care. However, little is known about how to measure safety of clinical diagnosis made through telehealth-facilitated primary care. Methods We used the seven-step Safer Dx Trigger Tool framework to develop an electronic trigger (e-trigger) tool to identify potential misse...

Objectives For patients requiring transfer to a higher level of care, excellent interfacility communication is essential. Our objective was to characterize verbal handoffs for urgent interfacility transfers of children to the PICU and compare these characteristics with known elements of high-quality intrahospital shift-to-shift handoffs. Design Mi...

Importance Lack of timely follow-up of cancer-related abnormal test results can lead to delayed or missed diagnoses, adverse cancer outcomes, and substantial cost burden for patients. Care delivery models, such as the Veterans Affairs’ (VA) Patient-Aligned Care Team (PACT), which aim to improve patient-centered care coordination, could potentially...

Background Managing diagnostic uncertainty is a major challenge in primary care due to factors such as the absence of definitive tests, variable symptom presentations and disease evolution. Maintaining patient trust during a period of investigative uncertainty, whilst minimising scope for diagnostic error is a challenge. Mismanagement can lead to d...

Background Diagnostic errors lead to patient harm; however, most research has been conducted in nonsurgical disciplines. We sought to characterize diagnostic error in the pre-, intra-, and postoperative surgical phases, describe their contributing factors, and quantify their impact related to patient harm. Methods We performed a retrospective anal...

Background Atypical presentations have been increasingly recognized as a significant contributing factor to diagnostic errors in internal medicine. However, research to address associations between atypical presentations and diagnostic errors has not been evaluated due to the lack of widely applicable definitions and criteria for what is considered...

BACKGROUND Atypical presentations have been increasingly recognized as a significant contributing factor to diagnostic errors in internal medicine. However, research to address associations between atypical presentations and diagnostic errors has not been evaluated due to the lack of widely applicable definitions and criteria for what is considered...

Background Emergency presentation (EP) of cancer, a new cancer diagnosis made following an emergency department (ED) visit, is associated with worse patient outcomes and greater organizational stress on healthcare systems. Pancreatic cancer has the highest rate of EPs among European studies but remains understudied in the U.S. Aims To evaluate the...

Background Emergency departments (EDs) are complex and fast-paced clinical settings where a diagnosis is made in a time-, information-, and resource-constrained context. Thus, it is predisposed to suboptimal diagnostic outcomes, leading to errors and subsequent patient harm. Arriving at a timely and accurate diagnosis is an activity that occurs aft...

BACKGROUND Emergency departments (EDs) are complex and fast-paced clinical settings where a diagnosis is made in a time-, information-, and resource-constrained context. Thus, it is predisposed to suboptimal diagnostic outcomes, leading to errors and subsequent patient harm. Arriving at a timely and accurate diagnosis is an activity that occurs aft...

Objectives Among patients with pancreatic cancer, studies show racial disparities at multiple steps of the cancer care pathway. Access to healthcare is a frequently cited cause of these disparities. It remains unclear if racial disparities exist in an integrated, equal access public system such as the Veterans Affairs healthcare system. Methods We...

122 Background: Colorectal cancers (CRCs) have the second highest cancer mortality for both sexes combined because approximately 60% of incident cases are not diagnosed until progression to later stages. Many patients with CRC experience cancer-related signs and symptoms up to a year prior to diagnosis, but they are often non-specific in nature, le...

Objectives No framework currently exists to guide how payers and providers can collaboratively develop and implement incentives to improve diagnostic safety. We conducted a literature review and interviews with subject matter experts to develop a multi-component ‘Payer Relationships for Improving Diagnoses (PRIDx)’ framework, that could be used to...

Authors of this Viewpoint present actionable steps for regulatory, industry, and health care organization practices to accelerate reduction of single-use plastics and help protect planetary and human health.

Persons living with dementia (PLWD) have high emergency department (ED) utilization. Little is known about using telemedicine with PLWD and caregivers as an alternative to ED visits for minor acute health problems. This qualitative interview-based study elicited caregivers' perspectives about the acceptability of telemedicine for acute complaints....

Background Guidelines recommend urgent chest X-ray for newly presenting dyspnoea or haemoptysis but there is little evidence about their implementation. Methods We analysed linked primary care and hospital imaging data for patients aged 30+ years newly presenting with dyspnoea or haemoptysis in primary care during April 2012 to March 2017. We exam...

Background Long-standing type 2 diabetes is a known risk factor for developing pancreatic cancer, however, its influence on cancer-associated outcomes is understudied. Aims To examine the associations between diabetes status and pancreatic cancer outcomes. Methods We identified patients diagnosed with pancreatic adenocarcinoma in the national Vet...

This Viewpoint examines various aspects of using generative artificial intelligence (AI) in health care, including assisting with making clinical diagnoses, and the challenges that come with using AI, such as ensuring the accuracy of the clinical data on which AI makes its diagnoses.

Background After testing, ensuring test results are communicated and actioned is important for patient safety, with failure or delay in diagnosis the commonest cause of malpractice claims in primary care worldwide. Identifying interventions to improve test communication from the decision to test through to sharing of results has important implicati...

Objective: Measures of diagnostic performance in cancer are underdeveloped. Electronic clinical quality measures (eCQMs) to assess quality of cancer diagnosis could help quantify and improve diagnostic performance. Materials and methods: We developed 2 eCQMs to assess diagnostic evaluation of red-flag clinical findings for colorectal (CRC; based...

Objectives: Effective interventions to prevent diagnostic error among critically ill children should be informed by diagnostic error prevalence and etiologies. We aimed to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU. Design: Multicenter retrospectiv...

( N Engl J Med . 2022;387:2469–2476) Threats to human health from climate instability include food and water shortages, heat, modified disease-vector ranges and active seasons, wildfires, and severe weather-related events, all of which have the potential to disrupt health care delivery as well. With awareness of the contribution of greenhouse gasse...

Background: Most people experience a diagnostic error at least once in their lifetime. Patients' experiences with their diagnosis could provide important insights when setting research priorities to reduce diagnostic error. Objective: Our objective was to engage patients in research agenda setting for improving diagnosis. Patient involvement:...

Objective The aim of this study is to understand how emergency departments (EDs) use health information technology (HIT), and specifically the electronic health record (EHR), to support implementation of delirium screening. Methods We conducted semi-structured interviews with 23 ED clinician-administrators, representing 20 EDs, about how they used...

Background: Patients with bladder and kidney cancer may experience diagnostic delays. Aim: To identify patterns of suboptimal care and contributors of potential missed diagnostic opportunities (MDOs). Design and setting: Prospective, mixed-methods study recruiting participants from nine general practices in Eastern England between June 2018 an...

Background Diagnostic errors, reframed as missed opportunities for improving diagnosis (MOIDs), are poorly understood in the paediatric emergency department (ED) setting. We investigated the clinical experience, harm and contributing factors related to MOIDs reported by physicians working in paediatric EDs. Methods We developed a web-based survey...

Introduction Computerised diagnostic decision support systems (CDDS) suggesting differential diagnoses to physicians aim to improve clinical reasoning and diagnostic quality. However, controlled clinical trials investigating their effectiveness and safety are absent and the consequences of its use in clinical practice are unknown. We aim to investi...

Interruptions are an inevitable occurrence in health care. Interruptions in diagnostic decision-making are no exception and can have negative consequences on both the decision-making process and well-being of the decision-maker. This may result in inaccurate or delayed diagnoses. To date, research specific to interruptions on diagnostic decision-ma...

Objectives: Electronic health record (EHR) inbox notifications can be burdensome for primary care providers (PCPs), potentially contributing to burnout. We estimated the association between changes in the quantities of EHR inbox notifications and PCP burnout. Study design: In this observational study, we tested the association between the percen...

Introduction Abdominal symptoms are common in primary care but infrequently might be due to an upper gastrointestinal (UGI) cancer. Patients’ descriptions may differ from medical terminology used by general practitioners (GPs). This may affect how information about abdominal symptoms possibly due to an UGI cancer are documented, creating potential...

Background Participation from clinician stakeholders can improve the design and implementation of health care interventions. Participatory design methods, especially co-design methods, comprise stakeholder-led design activities that are time-consuming. Competing work demands and increasing workloads make clinicians’ commitments to typical participa...

Despite the high frequency of diagnostic errors, multiple barriers, including measurement, make it difficult learn from these events. This article discusses Measure Dx, a new resource from the Agency for Healthcare Research and Quality that translates knowledge from diagnostic safety measurement research into actionable recommendations. Measure Dx...

Addressing environmental pollution and climate change is one of the biggest sociotechnical challenges of our time. While information technology has led to improvements in healthcare, it has also contributed to increased energy usage, destructive natural resource extraction, piles of e-waste, and increased greenhouse gases. We introduce a framework...

Introduction Adrenal mass management guidelines are insufficiently applied, and timeliness of treatment is unknown. We evaluated missed opportunities to promptly diagnose and treat adrenal tumors that ultimately required adrenalectomy. Methods From the Veterans Affairs Corporate Data Warehouse, we identified patients who underwent adrenalectomy (2...

Introduction Fewer cancer diagnoses have been made during the COVID-19 pandemic. Pandemic-related delays in cancer diagnosis could occur from limited access to care or patient evaluation delays (e.g., delayed testing after abnormal results). Follow-up of abnormal test results warranting evaluation for cancer was examined before and during the pande...

Background Most health care organizations (HCOs) find diagnostic errors hard to address. The research team developed a checklist (the Safer Dx Checklist) of 10 high-priority safety practices HCOs can use to conduct a proactive risk assessment to address diagnostic error. Methods First, the team identified potential practices based on reviews of re...

Introduction Researchers are increasingly developing algorithms that impact patient care, but algorithms must also be implemented in practice to improve quality and safety. Objective We worked with clinical operations personnel at two US health systems to implement algorithms to proactively identify patients without timely follow-up of abnormal te...

Objective: To identify challenges and pragmatic strategies for improving diagnostic safety at an organizational level using concepts from learning health systems METHODS: We interviewed 32 safety leaders across the USA on how their organizations approach diagnostic safety. Participants were recruited through email and represented geographically di...