Pa Patient Saf Advis 2018 Oct 31;15(Suppl 1):1.
Welcome to the Special Issue
Anesthesiology, Cardiology, Critical Care, Emergency Medicine, Oncology
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Regina Hoffman, MBA, BSN, RN, CPPS
Executive Director, Pennsylvania Patient Safety Authority


It is with great pleasure that I present to you the first special edition of the Pennsylvania Patient Safety Advisory. This issue is intended to bring awareness of the challenges involved in the diagnostic process. Beyond that is the hope of sparking creative solutions as we embrace these challenges.

Often in life, we are faced with not just one problem but many. Focus divided, we turn to multitasking and reprioritization, only to be ultimately left with feelings of frustration and failure. As mortal beings, we simply cannot do it all. We must be selective with the mantles we don if we aspire toward success. Choosing a problem that is as complex as healthcare itself is not a first choice for many. However, these are the types of problems that we must address—these are the ones that matter most.

Whether you are a physician, nurse, allied health provider, or healthcare leader, my plea to you is to choose improving diagnosis as one of your top priorities. Our healthcare facilities can have all the luxuries of a five-star hotel, the most helpful and kindest staff on the planet, the best food, the quietest environment, and the shortest wait times, but none of that truly matters if we cannot positively affect the health outcome for the patient.

Providing a correct diagnosis provides the basis for appropriate treatment options, informed choices, quality of life, quality of care, and ultimately, satisfaction with the healthcare system and the people who make up that system.

When something goes wrong in the diagnostic process, we remember. These are the stories that we relive and replay over and over, trying to find where a wrong turn was taken. This is the middle-aged woman who is surely just having another episode of anxiety accompanied by tightness in her chest. This is the older gentleman who fell off a ladder and has a fractured rib and a suspicious shadow on his chest radiograph that may or may not be followed up by someone. This is my mother-in-law who passed away from oral cancer that went undiagnosed for more than a year. We remember these events. They change us.

Improving diagnosis is a complex issue that is best tackled through a multifaceted approach that considers multiple perspectives, to build a foundation for improvement. We need innovative solutions to both new and age-old problems, embracing not only a culture of safety but a culture of creativity and inclusion, as well. In this issue, we bring some of these perspectives together—the patient, the data, thought leaders, healthcare facilities, and patient safety experts. All are necessary and vital to success.

My hope is that this issue serves as a catalyst for you to engage in this important work. Only after securing a proper foundation are the tallest skyscrapers built. The hard work begins at the foundation and it begins with all of us.


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