Journal & Resources
Pennsylvania Patient Safety Advisory
October 31, 2018, Vol. 15, Suppl. 1
Share Download Masthead
201810
Welcome to the Special Issue
Regina Hoffman, executive director, introduces the Advisory special issue, which is intended to bring awareness of the challenges involved in the diagnostic process.
Identifying and Learning from Events Involving Diagnostic Error: It’s a Process
Healthcare facilities can act now by using the modified DEER taxonomy to classify events from various sources, identify vulnerabilities in the diagnostic process, and prioritize areas of opportunity for learning and improvement.
Beyond the Lab: The Link between Health IT and Laboratory Test Problems
As the role of health IT in the laboratory testing process has advanced, so too has the possibility for patient safety to be compromised in new and unexpected ways.
Ask the Experts: A Roundtable Discussion with Some of the Nation's Leaders in Improving Diagnosis
In the spring of 2018, the Pennsylvania Patient Safety Authority convened an expert panel of 10 speakers to discuss issues in diagnostic error and strategies for improvement.
Misdiagnosis Can Cause Guilt for Those Seeking Resolution: From the Bedside to the Courtroom, the Perspective of a Clinician Turned Malpractice Attorney
Veronica Richards, board member, discusses how, as a team, the practitioner and patient can avoid the guilt associated with diagnostic error and its aftermath, by working through the differential diagnosis process together to improve patient safety.
The Star of the Diagnostic Journey: Assessing Patient Perspectives
The needs of every patient may be different; still, healthcare professionals should view the patient and family as a focal point in the journey to diagnosis.
Failures in the Diagnostic Process When Assessing Suicidal Intent
Improving information gathering at all stages of the patient’s crisis and ensuring that relevant data is communicated throughout the continuum of care can contribute to a more accurate diagnostic process.
From Virtual Autopsies to Expedited Stroke Detection: How Facilities are Improving the Diagnostic Process
The Pennsylvania Patient Safety Authority invited healthcare facility and/or team submissions that demonstrated improving diagnosis or decreasing diagnostic error. The chosen submissions are featured in this collection.
Getting Creative: Harnessing Synergy to Tackle Big Patient Safety Challenges
Authors share a conceptual framework that can be used to tackle any complex patient safety challenge, as well as a learning journey in progress to address diagnostic error in Pennsylvania following the framework.
Acquiring Diagnostic Skill: Understanding the Decision Making Processes Used by Experts
Dr. Ellen Deutsch, medical director and editor, and a coauthor discuss how contemporary Safety-II principles align with the premise that providing appreciation and reinforcing successful identification of diagnostic patterns will improve the diagnostic process.
Improving Diagnosis: Action and Insights
Rebecca Jones, director of innovation and strategic partnerships, discusses highlights from the Advisory special issue and explains that theory and conceptual understanding of diagnostic error are important, but understanding must be translated into actions that lead to solutions to improve diagnosis and reduce harm and death from diagnostic error.