Patient Safety Topics
Diagnostic Improvement

​​​​​​​​​​​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

Educational Tools

Modified DEER Taxonomy
This adapted taxonomy may be used to classify where a failure occurred during the diagnostic process.

Diagnostic Process – Patient​
​​A poster geared towards patients being an active part of their diagnosis.
A poster geared towards healthcare workers and the diagnostic process.

Influencing a Culture of Learning from Diagnostic Errors at a Health System​

At Geisinger, the multidisciplinary Committee to Improve Clinical Diagnosis and the Safer Dx Learning Lab (a collaboration with Baylor College of Medicine) are taking a systematic approach to learn how health care systems can enhance the safety and accuracy of the diagnostic process. Join Divvy Upadhyay, MD, MPH, program lead and scientist in the division of quality, safety, and patient experience at Geisinger, to understand how this “learning health system” approach is being implemented to improve diagnostic safety across the health system.

A Cognitive Bias Think Tank: Thinking, Talking, Making a Change

The Children’s Hospital of Philadelphia (CHOP) has been on journey to overcome the cognitive biases that may contribute to diagnostic error. Join Ursula Nawab, MD, Avram H. Mack, MD, and Andrea Colfer, MSN, as they discuss various aspects of CHOP’s Cognitive Bias Think Tank, including its history and formation, current objectives, quality improvement initiatives, and next steps to inform future work.

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

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

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

​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.

In the spring of 2018, the Authority convened an expert panel of 10 speakers to discuss issues in diagnostic error and strategies for improvement.  


Safety Tips for Patients