Mark L Graber

RTI International | RTI International

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...

Diagnostic errors comprise the leading threat to patient safety in healthcare today. Learning how to extract the lessons from cases where diagnosis succeeds or fails is a promising approach to improve diagnostic safety going forward. We present up-to-date and authoritative guidance on how the existing approaches to conducting root cause analyses (R...

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...

Objectives Patients with mental illness are less likely to receive the same physical healthcare as those without mental illness and are less likely to be treated in accordance with established guidelines. This study employed a randomized experiment to investigate the influence of comorbid depression on diagnostic accuracy. Methods Physicians were...

Background Clinician notes are structured in a variety of ways. This research pilot tested an innovative study design and explored the impact of note formats on diagnostic accuracy and documentation review time. Objective To compare two formats for clinical documentation (narrative format vs. list of findings) on clinician diagnostic accuracy and...

In the quest to improve diagnosis, a great deal of attention has already been focused on how to optimize clinical reasoning, and the importance of System 1 and System 2 processing. In this essay we consider the role of ‘insight’, a relatively overlooked pathway for arriving at the correct diagnosis. Insight refers to spontaneous emergence of the co...

Objectives: A lack of consensus around definitions and reporting standards for diagnostic errors limits the extent to which healthcare organizations can aggregate, analyze, share, and learn from these events. In response to this problem, the Agency for Healthcare Research and Quality (AHRQ) began the development of the Common Formats for Event Rep...

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...

Objectives Improving diagnosis-related education in the health professions has great potential to improve the quality and safety of diagnosis in practice. Twelve key diagnostic competencies have been delineated through a previous initiative. The objective of this project was to identify the next steps necessary for these to be incorporated broadly...

Background Errors in reasoning are a common cause of diagnostic error. However, it is difficult to improve performance partly because providers receive little feedback on diagnostic performance. Examining means of providing consistent feedback and enabling continuous improvement may provide novel insights for diagnostic performance. Methods We dev...

We describe the case of Jessica Barnett, an adolescent girl whose repeated episodes of syncope and near-syncope were ascribed to a seizure or anxiety disorder. The correct diagnoses (congenital long QT syndrome; arrythmogenic right ventricular cardiomyopathy) were established by autopsy and genetic studies only after her death at age 17. The perspe...

Diagnostic errors are among the most common medical errors and the deadliest. The National Academy of Medicine recently concluded that diagnostic errors represent an urgent national concern. Their first recommendation to address this issue called for promoting the key role of the nurse in the diagnostic process. Registered nurses across clinical se...

Objectives The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and descri...

Background Communication failures involving test results contribute to issues of patient harm and sentinel events. This article aims to synthesise review evidence, practice insights and patient perspectives addressing problems encountered in the communication of diagnostic test results. Methods The rapid review identified ten systematic reviews an...

Objectives: There is a pressing need for nurses to contribute as equals to the diagnostic process. The purpose of this article is twofold: (a) to describe the contributing factors in diagnosis-related and failure-to-monitor malpractice claims in which nurses are named the primary responsible party and (b) to describe actions healthcare leaders can...

Diagnosis is the cornerstone of providing safe and effective medical care. Still, diagnostic errors are all too common. A key to improving diagnosis in practice is improving diagnosis education, yet formal education about diagnosis is often lacking, idiosyncratic, and not evidence based. In this Invited Commentary, the authors describe the outcomes...

Background: As many as 90% of patients develop anemia by their third day in an intensive care unit (ICU). We evaluated the efficacy of interventions to reduce phlebotomy-related blood loss on the volume of blood lost, hemoglobin levels, transfusions, and incidence of anemia. Methods: We conducted a systematic review and meta-analysis using the L...

The American Association of Colleges of Pharmacy, the Accreditation Council for Pharmacy Education, and the Center for the Advancement of Pharmacy Education frame patient safety from the perspective of medication management, which is also the current focus of pharmacy education and training. With the growing appreciation that diagnostic errors repr...

Supplementary Material for doi.org/10.1515/dx-2018-0107 - Competencies for Improving Diagnosis

Background Given an unacceptably high incidence of diagnostic errors, we sought to identify the key competencies that should be considered for inclusion in health professions education programs to improve the quality and safety of diagnosis in clinical practice. Methods An interprofessional group reviewed existing competency expectations for multi...

In 2015, the Institute of Medicine, which was recently renamed the National Academy of Medicine, identified diagnostic error as an urgent patient safety concern in their report Improving Diagnosis in Health Care. The report's foremost recommendation is to promote team-based diagnosis, specifically calling for the patient and the nursing staff to be...

The purpose of this article is to synthesise review evidence, practice and patient perspectives on interventions to reduce diagnostic error in emergency departments (EDs). A rapid review methodology identified nine systematic reviews for inclusion. Six practice interviews were conducted to identify local contextual insights and implementation consi...

Background: Laboratory and medication data in electronic health records create opportunities for clinical decision support (CDS) tools to improve medication dosing, laboratory monitoring, and detection of side effects. This systematic review evaluates the effectiveness of such tools in preventing medication-related harm. Methods: We followed the...

This is a case report involving diagnostic errors that resulted in the death of a 15-year-old girl, and commentaries on the case from her parents and involved providers. Julia Berg presented with fatigue, fevers, sore throat and right sided flank pain. Based on a computed tomography (CT) scan that identified an abnormal-appearing gall bladder, and...

This review considers the feasibility of reducing or eliminating the three major categories of diagnostic errors in medicine: 1. ''No-fault errors'' occur when the disease is silent, presents atypically, or mimics something more common. These errors will inevitably decline as medical science advances, new syndromes are identified, and diseases can...

Diagnostic error is increasingly recognized as a major patient safety concern. Efforts to improve diagnosis have largely focused on safety and quality improvement initiatives that patients, providers, and health care organizations can take to improve the diagnostic process and its outcomes. This educational policy brief presents an alternative stra...

Failure to follow up test results pending at discharge (TPAD) from hospitals or emergency departments is a major patient safety concern. The purpose of this review is to systematically evaluate the effectiveness of interventions to improve follow‐up of laboratory TPAD. We conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using s...

Diagnostic safety could theoretically be improved by high-level interventions, such as improving clinical reasoning or eliminating system-related defects in care, or by focusing more specifically on a single problem or disease. In this review, we consider how the timely diagnosis of sepsis has evolved and improved as an example of the disease-focus...

Diagnostic error is a prevalent, harmful, and costly phenomenon. Multiple national health care and governmental organizations have recently identified the need to improve diagnostic safety as a high priority. A major barrier, however, is the lack of standardized, reliable methods for measuring diagnostic safety. Given the absence of reliable and va...

Successful coverage of Diagnosis articles in the prestigious PubMed database represents a significant accomplishment for our young journal, and we hope that all our readers will be as enthusiastic as we are for this milestone in the journal’s history.

Despite diagnosis being the key feature of a physician’s clinical performance, this is the first book that deals specifically with the topic. In recent years, however, considerable interest has been shown in this area and significant developments have occurred in two main areas: a) an awareness and increasing understanding of the critical role of c...

Background A 2015 National Academy of Medicine report on improving diagnosis in health care made recommendations for direct action by hospitals and health systems. Little is known about how health care provider organizations are addressing diagnostic safety/quality. Methods This study is an anonymous online survey of safety professionals from US h...

Surgical diagnostic errors are clinically and financially costly. Efforts to identify, monitor, and reduce the rates of these errors are urgently needed. Diagnostic error may involve various types of overlapping missed opportunities to make a correct and timely diagnosis; a diagnosis may be missed completely, the wrong one may be provided, or diagn...

Diagnostic error may be the largest unaddressed patient safety concern in the United States, responsible for an estimated 40,000–80,000 deaths annually. With the electronic health record (EHR) now in near universal use, the goal of this narrative review is to synthesize evidence and opinion regarding the impact of the EHR and health care informatio...

The National Academy of Medicine (NAM) in the recently issued report Improving Diagnosis in Health Care outlined eight major recommendations to improve the quality and safety of diagnosis. The #1 recommendation was to improve teamwork in the diagnostic process. This is a major departure from the classical approach, where the physician is solely res...

Timely and accurate diagnosis is foundational to good clinical practice and an essential first step to achieving optimal patient outcomes. However, a recent Institute of Medicine report concluded that most of us will experience at least one diagnostic error in our lifetime. The report argues for efforts to improve the reliability of the diagnostic...

Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, ‘Improving Diagnosis in Health Care’, con...

Recent research investigating diagnosis has generally relied upon one of two approaches to categorize and assess the antecedents of diagnostic error: (a) describing diagnostic error as a result of flaws in human cognition or (b) explaining diagnostic error as a result of working with complex health information systems. Each approach has uncovered i...

To the Editor: Palmer and Clegg (Aug. 6 issue)(1) provide a comprehensive review of electrolyte disturbances in patients with diabetes. To explain the presence of hyperkalemia in patients with type 4 renal tubular acidosis, the authors adopt the classic explanation of potassium retention due to defective potassium secretion; this defective secretio...

The IOM reports have emphasized that large gaps, chasms, separate the current state from the goal of providing safe health care. The newest volume in this series, Improving Diagnosis in Health Care, makes an effective case that this also applies to the goal of providing safe, effective, and timely diagnosis. Fortunately, the report also represents...

The IOM report ‘Improving Diagnosis in Health Care’ represents a major advance in summarizing the problem of diagnostic error. Three new concepts in the report will be helpful in future efforts to understand and improve the diagnostic process: a new definition of diagnostic error, a new framework for understanding the diagnostic process, and a new...

The 1999 Institute of Medicine (IOM) report To Err Is Human transformed thinking about patient safety in U.S. health care. On its 15th anniversary, a topic largely missing from that report is finally getting its due. With its new report, Improving Diagnosis in Health Care, the IOM has acknowledged the need to address diagnostic error as a "moral, p...

Background: There is widespread agreement that the full potential of health information technology (health IT) has not yet been realized and of particular concern are the examples of unintended consequences of health IT that detract from the safety of health care or from the use of health IT itself. The goal of this project was to obtain additiona...

Purpose: Experienced clinicians derive many diagnoses intuitively, because most new problems they see closely resemble problems they've seen before. The majority of these diagnoses, but not all, will be correct. This study determined whether further reflection regarding initial diagnoses improves diagnostic accuracy during a high-stakes board exam...

Patient Safety and Healthcare Improvement at a Glance is a timely and thorough overview of healthcare quality written specifically for students and junior doctors and healthcare professionals. It bridges the gap between the practical and the theoretical to ensure the safety and wellbeing of patients. Featuring essential step–by–step guides to inter...

Few studies have described the cognitive components that characterize the diagnostic process. This article illustrates the use of work domain analysis to create a functional depiction of diagnosis. The resulting abstraction-decomposition space clarifies the medical diagnostician’s work domain and provides a glimpse into the fundamental cognitive fe...

Background: Checklists have been shown to improve performance of complex, error-prone processes. To develop a checklist with potential to reduce the likelihood of diagnostic error for patients presenting to the Emergency Room (ER) with undiagnosed conditions. Methods: Participants included 15 staff ER physicians working in two large academic cen...

The impact of second opinions on diagnosis in radiology and pathology is well documented; however, the value of patient-initiated second opinions for diagnosis and treatment in general medical practice is unknown. We conducted a systematic review of patient-initiated second opinions to assess their impact on clinical outcomes and patient satisfacti...

Although health care organizations (HCOs) are intensely focused on improving the safety of health care, efforts to date have almost exclusively targeted treatment-related issues. The literature confirms that the approaches HCOs use to identify adverse medical events are not effective in finding diagnostic errors, so the initial challenge is to iden...

The field of diagnosis is hardly static. Taking a step back, advances in diagnosis have been dramatic over the past few decades, and promise to accelerate going forward. Progress will be created through three main drivers: Continuing advances in the tools we use for diagnosis, adoption and use of electronic resources, and applying quality improveme...

Many diagnostic errors are associated with laboratory testing, and many of these are preventable. However, a reduction in testing-related diagnostic errors (TDE) is hindered by the absence of a well-defined relationship between diagnostic harm and the testing process (whether from laboratory or non-laboratory sources) as well as by a lack of releva...

Although healthcare quality and patient safety have longstanding international attention, the target of reducing diagnostic errors has only recently gained prominence, even though numerous patients, families and professional caregivers have suffered from diagnostic mishaps for a long time. Similarly, patients have always been involved in their own...

A wide variety of research studies suggest that breakdowns in the diagnostic process result in a staggering toll of harm and patient deaths. These include autopsy studies, case reviews, surveys of patient and physicians, voluntary reporting systems, using standardised patients, second reviews, diagnostic testing audits and closed claims reviews. Al...

Cases of delayed, missed, and incorrect diagnosis are common, with an incidence in the range of 10% to 20%.1 Some errors in diagnosis stem from mistakes in the interpretation of diagnostic tests. For example, pathology, radiology, and the clinical laboratory each have error rates of 2% to 5%. Superimposed on these testing errors are the ubiquitous...

Purpose: Despite shorter duty hours, fatigue remains a problem among medical residents. The authors tested the effect of a short, mid-day nap on the cognitive functioning and alertness of first-year internal medicine (IM) residents during normal duty hours. Method: This was a controlled, interventional study performed between July 2008 and April...

Errors in clinical reasoning occur in most cases in which the diagnosis is missed, delayed or wrong. The goal of this review was to identify interventions that might reduce the likelihood of these cognitive errors. We searched PubMed and other medical and non-medical databases and identified additional literature through references from the initial...

Diagnostic errors (missed, delayed or wrong diagnosis) have recently gained attention and are associated with significant preventable morbidity and mortality. The authors reviewed the recent literature and identified interventions that address system-related factors that contribute directly to diagnostic errors. The authors conducted a comprehensiv...

Differential diagnosis (DDX) generators are computer programs that generate a DDX based on various clinical data. We identified evaluation criteria through consensus, applied these criteria to describe the features of DDX generators, and tested performance using cases from the New England Journal of Medicine (NEJM©) and the Medical Knowledge Self A...

Diagnostic errors are common and can often be traced to physicians' cognitive biases and failed heuristics (mental shortcuts). A great deal is known about how these faulty thinking processes lead to error, but little is known about how to prevent them. Faulty thinking plagues other high-risk, high-reliability professions, such as airline pilots and...

Background: Differential diagnosis (DDX) generators have existed for some time, but their use has not been widely adopted in practice. We identified and described the features of a current list of DDX generators. Methods: We performed a Google search and a literature search using a series of subject headings (MESH) and keywords to identify progra...

If implemented correctly, the patient-centered medical home (PCMH) can potentially address many current safety concerns in primary care. One highly relevant but underemphasized safety concern is diagnostic error (ie, missed, delayed, or incorrect diagnosis),¹ possibly the leading type of error in primary care. Diagnostic errors are the single large...

The topic of diagnostic error is a relatively new one in the academic arena and lacks an organized research agenda. Participants at "Diagnostic Error in Medicine- 2008" formally considered this issue and provided initial suggestions. Recommendations were made to standardize taxonomies and definitions, especially in regard to what constitutes a dela...

Diagnostic error typically involves both system-related and cognitive root causes. Educational interventions are proposed to address both of these dimensions: In regard to system-related origins, education should focus on communication skills, including handoffs. In regard to cognitive shortcomings, educators need to consider both normative approac...

Deriving an appropriate differential diagnosis is a key clinical competency, but there is little data available on how medical students learn this skill. Software resources designed to complement clinical reasoning might be asset in helping them in this task. The goals of this study were to identify the resources third year medical students use to...