About Us
Center of Excellence for Improving Diagnosis

Overview

According to the National Academy of Medicine, most people will experience at least one diagnostic error in their lifetime, sometimes with fatal outcomes. The toll of diagnostic error in the United States is estimated at 40,000 to 80,000 deaths a year.

Through its Center of Excellence, the Authority provides leadership, guidance, and support for health care facilities and systems, providers, patients, and all interested stakeholders to improve diagnosis throughout the Commonwealth.

The Center of Excellence focuses on the following key objectives while working toward its vision of accurate and timely diagnoses communicated to all patients:

  • Gathering, synthesizing, and sharing information to broaden awareness and knowledge about this complex topic
  • Building partnerships and creating new networks between organizations to accelerate and scale improvements
  • Facilitating the development and implementation of novel solutions and inspiring healthcare providers and patients to work together to strengthen the diagnostic process

For more information about the Center of Excellence for Improving Diagnosis, email PSA-improvingdiagnosis@pa.gov.

 News and Resources

Resources

For more information, please visit our Patient Safety Topic on Diagnostic Error.

In the News

Pennsylvania launches new center to improve diagnosis.

Webinars

Diagnostic Error: A Patient Safety Imperative: Featuring Becky Jones and Dr. Tim Mosher

https://jdc.jefferson.edu/hpforum/125/

Diagnostic errors are a complex and often overlooked problem in the field of patient safety. While various cognitive and system factors contribute to the problem, there are many opportunities for improvement.

Reducing Harm by Getting Patients the Right Diagnosis at the Right Time: Featuring Paul Epner, Dr. David Newman-Toker and Dana Siegal

https://www.youtube.com/watch?v=tYRd8xbFQxQ

Diagnostic errors are the most common, catastrophic and costly of all medical errors—resulting in thousands of patients suffering serious harm every year. The healthcare community is beginning to understand where and when they happen most frequently, and with the highest severity. It is time to take steps to prevent misdiagnoses and ensure patients get the right diagnosis at the right time.

Addressing Diagnostic Error: Featuring Dr. Mark Graber

https://www.youtube.com/watch?v=cxTv-JuhF0s&list=PLQ8bRZ9aQtty53wZSw9ET-sn4Z-KejsA6

Discussed are the likelihood of diagnostic error in physician practices, the most common system-related and cognitive causes of diagnostic error, and interventions to reduce the risk of harm from diagnostic error.

Literature

Improving Diagnosis in Health Care

https://www.nap.edu/catalog/21794/improving-diagnosis-in-health-care

Getting the right diagnosis is a key aspect of health care: it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794.

Recommendations for Improving Diagnosis in Health Care—Institute of Medicine

http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2015/Improving-Diagnosis/Diagnosis_Recommendations.pdf

The Institute of Medicine provides eight goals to improve diagnosis in healthcare including facilitating more effective teamwork among health care professionals, patients, and their families; and enhancing health care professional education and training in the diagnostic process.

Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations

http://www.qualityforum.org/Publications/2019/10/Reducing_Diagnostic_Error_-_Measurement_Considerations.aspx

The Diagnostic Process and Outcomes domain of the Framework addresses the actions and processes that are carried out by healthcare providers and/or teams to develop, refine, and confirm a diagnosis, or to explain the patient's health problem. The updated environmental scan identified several articles that add additional breadth to some subdomains, describing additional interventions and approaches that may be useful in reducing diagnostic error.

Serious misdiagnosis-related harms in malpractice claims: The "Big Three"—vascular events, infections, and cancers

https://www.degruyter.com/downloadpdf/j/dx.2019.6.issue-3/dx-2019-0019/dx-2019-0019.pdf

The "Big Three" diseases—vascular events, infections, and cancers—account for about three-fourths of serious misdiagnosis-related harms. Initial efforts to improve diagnosis should focus on vascular events, infections, and cancers. 

Organizations

Patient Safety Authority Center of Excellence for Improving Diagnosis

http://patientsafety.pa.gov/PatientSafetyAuthority/Pages/CenterofExcellence.aspx

The Center of Excellence focuses on the following key objectives while working toward its vision of accurate and timely diagnoses communicated to all patients:

  • Gathering, synthesizing, and sharing information to broaden awareness and knowledge about this complex topic
  • Building partnerships and creating new networks between organizations to accelerate and scale improvements
  • Facilitating the development and implementation of novel solutions and inspiring healthcare providers and patients to work together to strengthen the diagnostic process

Society to Improve Diagnosis in Medicine

https://www.improvediagnosis.org/

The Society to Improve Diagnosis in Medicine (SIDM) catalyzes and leads change to improve diagnosis and eliminate harm from diagnostic error. They work in partnership with patients, their families, the healthcare community, and every interested stakeholder. SIDM is the only organization focused solely on the problem of diagnostic error and improving the accuracy and timeliness of diagnosis. SIDM offers resources for clinicians, educators, and patients including checklists, courses, and toolkits.

Coalition to Improve Diagnosis

https://www.improvediagnosis.org/cid/

The Coalition to Improve Diagnosis, convened and led by the Society to Improve Diagnosis in Medicine (SIDM), is a collaboration of more than 50 leading healthcare organizations focused on ensuring that diagnoses are accurate, communicated and timely. Coalition members represent doctors, nurses, testing professionals, patients and their families, employers, researchers, policymakers, educators and leading health organizations and government agencies involved in patient care.

National Quality Forum

https://www.qualityforum.org

The National Quality Forum (NQF) is a not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in healthcare. The NQF mission is to improve health care through endorsement of consensus-based national standards for use of performance data. These data provide meaningful information about whether care is safe, timely, beneficial, patient-centered, equitable, and efficient.

Core Team

Rebecca Jones, MBA, BSN, RN, CPHRM, CPPS, Center Director
Rebecca Jones
MBA, BSN, RN, CPHRM, CPPS
Center Director
Timothy J. Mosher, MD, Physician Advisor
Timothy J. Mosher
MD
 
Physician Advisor
Caitlyn Sidrane, MPH, Marketing Lead
Caitlyn Sidrane
MPH
Marketing Lead
Teresa Plesce, Team Coordinator
Teresa Plesce
 
Team Coordinator
Jeffrey Bomboy, BS, RN, CPPS, Core Team Lead
Jeffrey Bomboy
BS, RN, CPPS
Core Team Lead
Catherine Reynolds, DL, MJ, BSN, RN, CPPS, Core Team Lead
Catherine Reynolds
DL, MJ, BSN, RN, CPPS
Core Team Lead
Susan Wallace, MPH, CPHRM, Core Team Lead
Susan Wallace
MPH, CPHRM, CPPS 
Core Team Lead
Robert Yonash, RN, CPPS, Core Team Lead
Robert Yonash
RN, CPPS
Core Team Lead

©2020 Pennsylvania Patient Safety Authority