Pennsylvania Patient Safety Authority. Center of Excellence for Improving Diagnosis. 2018 Jun.
The center has the objectives of gathering, synthesizing, and sharing information to broaden awareness and knowledge; building partnerships and creating new networks between organizations to accelerate and scale improvements; and facilitating the development and implementation of novel solutions and inspiring healthcare providers and patients to work together to strengthen the diagnostic process.
Diagnostic Team
The new diagnostic team. 2017.
This article discusses an expanded diagnostic team—including nurses and allied health professionals, as well as the patient—that supports the diagnostic process.
Patient involvement strategies for diagnostic error mitigation. 2013.
This article contains a list of patient tactics for preventing and detecting diagnostic errors, including telling your story well, being an informed patient, and ensuring follow-up on testing. The authors encourage patients to report diagnostic error.
Defining the role of nurses in diagnostic error prevention. 2017.
This article defines a framework for nursing engagement in the diagnostic process and includes an approach to addressing barriers to nurses participating as full members of the diagnostic team.
Patient's toolkit for diagnosis. 2015.
This toolkit helps patients prepare for a visit with their healthcare provider by providing a format with prompts for telling their story clearly.
Testing
Lost surgical specimens, lost opportunities. 2005.
This article presents risk reduction strategies, including specimen retrieval, reducing reliance on memory, and chain of custody.
In vitro hemolysis: delays may pose safety issues. 2007.
This article presents risk reduction strategies including timely and accurate testing processes such as phlebotomy site selection and analysis of adverse events.
Beyond the lab: the link between health IT and laboratory testing. 2018.
This article presents risk reduction strategies including assembling a multidisciplinary team to evaluate and improve the total testing process, simplifying test names in order menus, monitoring the display of results, and establishing a communication plan for incomplete specimens, cancelled specimens, and amended results.
Hypothesis Generation
Clinical reasoning toolkit. [accessed 2018].
This toolkit shares resources as an introduction to clinical reasoning.
Monitoring/Follow-up
Alarm interventions during medical telemetry monitoring: a failure mode and effects analysis. 2008.
This is a comprehensive failure mode and effects analysis on telemetry monitoring, with detailed mitigation strategies about alarm management.
Connecting remote cardiac monitoring issues with care areas. 2009.
This article presents risk reduction strategies to enhance communication about remote cardiac monitoring of patients in noncritical care areas.
Physiologic alarm management. 2011.
This article identifies potential contributing factors to patient deaths associated with physiologic alarm monitoring and includes mitigation strategies.
Managing patient access and flow in the ED to improve patient safety. 2010.
This article includes strategies to increase patient safety and improve quality during the emergency department (ED) visit from point of arrival through diagnostic evaluation.
Patient flow in the ED - diagnostic evaluation through disposition decision. 2015.
This article includes general principles to enhance patient safety related to the diagnostic process in the ED setting.
Patient flow in the ED - after disposition through departure. 2015.
This article includes strategies to enhance patient safety related to monitoring, communication, and a reference from the Agency for Healthcare Research and Quality on a feedback mechanism about a patient's ED diagnosis versus final diagnosis.
Warming blankets and patient harm. 2017.
This article includes strategies to enhance patient monitoring practices while using warming devices.
Early warning systems: the next level of rapid response. 2012
This article describes the use of an early warning system, based on physiologic signals, to assist staff in recognizing high-risk patients before they deteriorate.
Failure to rescue and nursing surveillance. 2003.
This article defines and outlines nursing surveillance as a strategy to prevent the inability to save a patient's life when he or she experiences a complication (i.e., failure to rescue).
Hospital and patient characteristics associated with death after surgery. 1992
This article coins the phrase "failure to rescue" and identifies patient characteristics associated with adverse occurrences.
