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Found 211 results
  1. News Article
    Doctors and the NHS could be sued for medical negligence over mistakes made by artificial intelligence tools used in diagnosing patients and suggesting their treatment, ministers are being warned. Under the law as it stands, medics and the health service can be held liable for patients being harmed or dying even if it was AI that made the errors that resulted in their suffering. The Medical Protection Society, which represents doctors accused of wrongdoing, says in a report that medics could become the “liability sink” – a target of clinical negligence lawsuits – for mistakes made by AI unless the law is overhauled. The NHS is using AI for more and more purposes, including to analyse scans and X-rays, generate summaries of doctors’ conversations with patients, and draft letters to patients. “The law has always struggled to keep up with technological change. But with AI, the pace of change is so rapid that this gap feels less like a step and more like a widening gulf,” said Dr Sarah Townley, the MPS’s deputy medical director. Giving an example of potential harm from AI errors, the MPS said AI could miss a tumour in a patient’s lung when reading an X-ray of their chest. This could result in the patient dying because the false reassurance from the AI would mean no treatment would be given and the cancer could then spread. Similarly, a patient could need surgery and treatment in intensive care for severe bleeding if an AI wrongly recommended increasing their dose of warfarin, a blood thinner used to treat the heart condition atrial fibrillation. In such scenarios there was a real and significant risk that a claim would be brought against a doctor in relation to the use of AI tools, the MPS said. “Under the current product liability framework in the UK, there is a risk that clinical negligence claims could be brought against the clinicians in these cases and that they would be held wholly liable,” it warns. Read full story Source: The Guardian, 9 June 2026
  2. Content Article
    On 30 July 2025 an investigation was commenced into the death of Pamela Ann Honeybone, who died at Scarborough General Hospital on 19 October 2024 aged 90. The investigation concluded at the end of the inquest on 23 September 2025.  The conclusion of the inquest was that: Pamela Ann Honeybone died as a consequence of naturally occurring disease. Diagnosis of her condition was delayed when another patient was scanned in error instead of Mrs Honeybone, but it has not been possible to determine on the balance of probabilities that this contributed to her death.  On the 19 of September 2024 Pamela Ann Honeybone was admitted to Scarborough General Hospital following a fall. She required CT scanning but another patient with the same first name underwent the investigation in error and its results were attributed to Mrs Honeybone. Mrs Honeybone’s condition continued to deteriorate and a CT scan undertaken on the 15 of October 2024 revealed the presence of an abdominal mass suggestive of lymphoma. Mrs Honeybone was moved to end of life care and she died at the hospital on the 19 of October 2024. Matters of concern: It was accepted in evidence that neither the doctor who escorted the wrong patient from the Emergency Department to radiology, nor the radiographer who undertook the CT scan on her, checked the identity of the patient in question. No transfer checklist was completed, and the patient was not asked to complete and/or sign the CT scanning questionnaire herself. No member of staff inquired as to the outcome of this patient’s CT scan prior to her discharge a few hours later. The scanning error was recognised by a radiologist on the 15th of October 2024, but was not conveyed to Mrs Honeybone’s treating team until late October, by which time she had died and her death had been scrutinised by the Medical Examiner and certified by her treating doctor as wholly natural and not requiring referral to the Coroner. As a result of the aforementioned delay, a Trust investigation did not commence until late November 2024. No prompt after action review therefore occurred in the hours and days after the error was recognised. When the Trust investigation did commence, staff directly involved either could not be identified or had no recollection of events. Despite hearing evidence that it was a doctor who would have escorted the wrong patient to scanning, the Trust Investigation focussed on nursing involvement with the patients in question and did not seek to identify and question medical team members. An Action Plan was drawn up as a result of the Trust Investigation, but for various reasons no audit of compliance with patient identification processes commenced until early August 2025, some ten months after Mrs Honeybone’s death. The results of the audit thus far were made available to me at inquest and indicate that 1 in 5 audited treatment encounters between staff of all grades and specialisms still occur without the patient being positively identified. The coroner heard evidence that while radiology transfer checklists are routinely completed ‘in hours’ at Scarborough Hospital when a dedicated HCA is on duty to perform this task, no such checklist is in use at the Trust’s York site at any time of the day. Mrs Honeybone’s misidentification occurred ‘out of hours’ at Scarborough when no designated person assumes responsibility for this task at that site. The coroner considers the above represent a continuing risk to others from misidentification and delayed responses to identified errors, with clear implications for patient safety.
  3. Content Article
    More information about "The invisible safety checkpoint: diagnostics and patient safety in NHS-contracted independent ophthalmic care"
    Patient safety in ophthalmology depends on the reliability of diagnostic information that informs clinical decisions. Within independent providers delivering NHS-contracted care, ophthalmic technicians undertake a wide range of physiological and psychophysical assessments, from advanced imagining and functional testing to preoperative measurements that shape condition management and surgical planning. This article explores diagnostics as an often unseen safety checkpoint. It reflects on how structured verification processes, clear escalation pathways and defined accountability within diagnostic teams strengthen system reliability. Viewing diagnostics through a patient safety lens highlights how safe care is sustained through multidisciplinary collaboration and robust system design rather than individual vigilance alone. The NHS increasingly delivers care through a mixed model in which independent providers undertake NHS-funded surgical pathways. This model can increase capacity and reduce waiting times. However, patient safety does not transfer automatically with contracts. It depends on robust systems, clear standards and well-prepared people. In ophthalmology, safety begins long before the surgeon enters the operating theatre. It begins in diagnostics with ophthalmic technicians (predominantly). Preoperative imaging, biometry, visual field testing and other screening inform surgical planning and intraocular lens power selection. National guidance from the Royal College of Ophthalmologists emphasises the importance of accurate biometry and appropriate preoperative assessment in reducing refractive surprise and avoidable harm.[1] When diagnostic governance is strong, risk is mitigated early in the pathway. When it is inconsistent, vulnerabilities may remain undetected. Diagnostic reliability as a safety principle Patient safety literature consistently demonstrates that harm in healthcare often arises not from single catastrophic failures but from accumulations of small system weaknesses.[2] In high volume cataract and glaucoma services, diagnostic processes operate under significant throughput pressure. In that environment, the reliability of measurement systems matters. Examples may include: Failure to recognise poor fixation during biometry. Acceptance of inconsistent keratometry readings without repeat measurement. Inadequate review of visual field reliability indices. Limited escalation of ambiguous imaging findings. Individually these may appear minor. Collectively they influence surgical accuracy and long term outcomes. This is not solely an ophthalmic technician issue. It is a system reliability issue. The role of ophthalmic technicians within the safety system Ophthalmic technicians working in both NHS trusts and independent providers frequently undertake (this is not an exhaustive list): Optical coherence tomography acquisition. Biometry measurement. Visual field testing. Corneal topography. Ultrasonography. Fundus photography. Specular microscopy. Data preparation for clinical decision making. The General Medical Council and NHS England both emphasise that safe delegation requires appropriate training, supervision and clarity of accountability.[3] Where ophthalmic technicians are appropriately trained and supported, structured approaches such as second checker systems, defined escalation thresholds and documented quality standards can strengthen safety by reducing single point failure risk. These systems align with wider patient safety principles embedded within the Patient Safety Incident Response Framework (PSIRF), which emphasises learning, system design and proactive risk reduction rather than individual blame.[4] Independent provider pathways and shared standards Independent providers delivering NHS care are subject to the same Care Quality Commission expectations regarding safety, governance and quality assurance.[5] Patients rightly expect consistent standards regardless of setting. Diagnostic governance in this context should include: Clear standard operating procedures aligned with national guidance. Documented competency frameworks. Regular audit of refractive outcomes and measurement consistency. Structured escalation pathways. Ongoing professional development. These measures support both clinicians and ophthalmic technicians. They strengthen the entire pathway. Capability before expectation Across healthcare there has been expansion of non-medical roles to address workforce pressures. The Health and Social Care Committee has highlighted that role expansion must be matched with training, supervision and system design to protect patient safety.[6] In ophthalmology, ophthalmic technician-led diagnostic services can improve efficiency and access. However, safe expansion depends on: Defined scope of practice. Clear supervision structures. Time for skill consolidation. Access to continuing professional development. Inclusion in governance discussions. When expectation outpaces preparation, risk increases. When preparation is prioritised, safety improves. Prevented harm is rarely visible A repeated scan due to inconsistent signal. A paused surgical listing due to anomalous measurements. An escalated concern about unreliable visual field data. These actions do not generate incident reports because harm was prevented. Safety science reminds us that high-reliability systems pay attention not only to adverse events but to near misses and everyday adjustments that prevent error.[7] Ophthalmic technicians often contribute to this layer of safety. Recognising that contribution is not about professional status. It is about understanding how the pathway functions as a whole. A shared responsibility This is not an argument that ophthalmic technicians alone safeguard patients. Surgeons, optometrists, nurses, managers and other non-clinical staff all contribute to safe care. Rather, it is an invitation to ensure that diagnostic work is fully integrated into patient safety conversations. Questions worth reflecting on include: How is diagnostic quality measured within surgical pathways? Are escalation thresholds clearly defined and psychologically safe to use? Is learning captured from preoperative discrepancies? Are diagnostic staff included in incident learning discussions? In NHS-contracted independent care, as in all healthcare settings, patient safety depends on system design, team functioning and reliable processes. Diagnostics is the first safety checkpoint in ophthalmic surgery. The people delivering it should be visible within the safety framework, not peripheral to it. References 1. The Royal College of Ophthalmologists, UK Ophthalmology Alliance. Quality Standard. Correct IOL implantation in cataract surgery. March 2018. 2. Reason J. Human Error, 1990; Cambridge University Press, Cambridge. 3. General Medical Council: Delegation and referral. Last accessed 2 March 2026. 4. NHS England. Patient Safety Incident Response Framework. Last accessed 2 March 2026. 5. Care Quality Commission. The fundamental standards of care. 23 December 2025. 6. House of Commons Health and Social Care Committee. Workforce burnout and resilience in the NHS and social care. Second Report of Session 2021-22. 8 June 2021. 7. Vanderhaegen F. Erik Hollnagel: Safety-I and Safety-II, the past and future of safety management. Cognition Technology and Work 17(3):461-464.
  4. Content Article
    Ambiguous or unnecessary radiologist recommendations for additional imaging (RAIs) can lead to excessive imaging use and diagnostic errors. The purpose of this paper was to determine the cumulative impacts of multifaceted technology-enabled interventions aimed at optimising RAI on RAI rate, actionability, and resolution over an 8-year period. Authors conclude that multifaceted interventions to optimize RAI improved the rate, actionability, and resolution of RAI.
  5. Content Article
    Every year in Australia, an estimated 140,000 people experience a diagnostic error. For 21,000 people, it causes serious harm. For 4,000 people, it’s fatal. In this blog, the authors make the case for a national policy that puts diagnostic safety on the agenda, and drives real change to prevent errors before more patients are harmed.
  6. News Article
    A first-time mum died from a bleed on the brain just days after giving birth following "inadequate care" by medics who sent her home twice from hospital, a coroner has ruled. Ilona Kazik, 32, suffered a major obstetric bleed just hours after her first child Antony was born via a planned c-section at Luton and Dunstable University Hospital. Read full story Source: Mirror, 25 November 2025
  7. News Article
    Too often, young people with serious illnesses are dismissed or told they’re “too young” to be sick – and Independent readers have been sharing their own experiences of being ignored by the NHS. Readers shared experiences of being dismissed by healthcare professionals, and speculated whether that was down to age, gender, or assumptions about their symptoms. One reader’s story mirrored the challenges faced by patients like 19-year-old Milli Tanner, who went to 13 GP appointments and A&E visits over two years before being diagnosed with stage 3 bowel cancer. She was initially told her symptoms were caused by piles, IBS, or her age, and faced long waits for urgent testing before finally receiving a diagnosis. Readers highlighted the emotional and physical toll of such dismissal, with one sharing being misdiagnosed for three years despite a private MRI showing multiple active MS lesions. Another described how a family’s Lynch Syndrome history was overlooked, contributing to preventable deaths from bowel and uterine cancer. Overall, Independent readers stressed that listening, taking symptoms seriously, and empowering patients are crucial to prevent young people from being failed by the system. Read full story Source: The Independent, 2 November 2025
  8. Content Article
    Over 75% of diagnostic errors in ambulatory care result from breakdowns in patient-clinician communication. Encouraging patients to speak up and ask questions has been recommended as one strategy to mitigate these failures. This scoping review in the Journal of Patient Safety aimed to identify, summarise and thematically map questions patients are recommended to ask during ambulatory encounters along the diagnostic process. This is the first step in a larger study to co-design a patient-facing question prompt list for patients to use throughout the diagnostic process.
  9. Content Article
    One in 20 outpatients in the United States experiences a diagnostic error each year, but there are no validated methods for collecting feedback from patients on diagnostic safety. This mixed-methods study in the Journal of Patient Safety examined patient experience surveys to determine whether patients’ free text comments indicated diagnostic breakdowns. The study aimed to evaluate associations between patient-perceived diagnostic breakdowns reported in free text comments and patients’ responses to structured survey questions. The authors concluded that patient feedback in routinely collected patient experience surveys is a valuable and actionable information source on diagnostic breakdowns in the ambulatory setting. The more easily monitored structured survey data provide a screening method to identify encounters that may have included a patient-perceived diagnostic breakdown and therefore require further examination.
  10. Content Article
    Guidelines for blood pressure (BP) measurement recommend arm support on a desk with the midcuff positioned at heart level. Still, nonstandard positions are used in clinical practice (eg, with arm resting on the lap or unsupported on the side). This study looked at the effect of commonly used arm positions on blood pressure (BP) measurements compared to the standard, recommended position. It found that commonly used, nonstandard arm positions during BP measurements substantially overestimate BP, highlighting the need for standardised positioning.
  11. Content Article
    In 2012, I could not have imagined that the greatest threat my husband faced in the hospital was not the brain bleed we came in to treat — but one of the most common post-surgical complications, venous thromboembolism (VTE). This deadly blood clot was growing in my husband, and no one on his care team knew it. In a few days, it would travel to his lungs and kill him. Simple steps, like a risk assessment and monitoring, could have been taken. However, these proven preventative measures were not taken.  Vonda Vaden Bates, a patient safety advocate, shares her story.
  12. Content Article
    The Royal College of Surgeons of Edinburgh launched a series of blogs in recognition of the World Patient Safety Day (WPSD) 2024 theme of "Improving Diagnosis for Patient Safety". RCSEd World Patient Safety Day 2024 A Novel Facial Cellulitis Pathway: Improving the Time to Surgery for Facial Necrotising Fasciitis Improving Diagnosis for Safety in Dentistry Using Audit to Improve Outcomes for Patients with Upper Tract Urothelial Cancer Diagnostic Safety in Surgery WHO World Patient Safety Day 2024: Improving Diagnosis for Patient Safety The Importance of Teamwork for Surgical Diagnostic Safety in Outpatients Challenges in the Diagnosis of Twin Silent Killers: Aortic Aneurysm and Acute Aortic Dissection Improving Diagnostic Safety in Orthopaedics NCEPOD: Prioritising Diagnostic Safety for Better Health Outcomes Protecting our Precious Gift of Life World Patient Safety Day 2024 — A View from the Bridge Can My Stool be Tested for Bowel Cancer? Virtual Diagnostics The Potential of AI to Help Reduce Diagnostic Errors Non-Technical Skills for Surgeons (NOTSS). Vignette 3 of 3. Leadership in Surgery: A Case Study Non-Technical Skills for Surgeons (NOTSS). Vignette 2 of 3. Team Communication: The Key to Clarity and Precisio Non-Technical Skills for Surgeons (NOTSS). Vignette 1 of 3. Situation Awareness: Staying Ahead of Potential Issues Enhancing Diagnostic Safety in Surgery Through Non-Technical Skills Diagnosing Acute Aortic Dissection – The Patient Perspective
  13. Content Article
    Each year, diagnostic errors account for an estimated 16% of preventable harm in health care. Data suggest that most adults will experience at least one diagnostic error in their lifetime, which can result in prolonged ill health, increased health care costs, or even preventable death. The theme for this year’s World Patient Safety Day (17 September 2024) was focused on improving diagnosis for patient safety, using the slogan “Get it right, make it safe!” Patient advocate, Sue Sheridan talks about how being engaged in the diagnostic journey can ensure timely and correct diagnosis. "It completely fractured my soul." Sue shares her heartbreaking story about her son and her husband. 
  14. News Article
    The family of a mother who died from cervical cancer after twice being wrongly told she had negative results have been awarded undisclosed damages. The misreporting of Louise Gleadell's cervical screening results was admitted by University Hospitals of Leicester NHS Trust following her death aged 38 in March 2018. An internal review in 2017 found the samples, taken four years apart, were not good enough to produce reliable results but neither Ms Gleadell - a mum to three boys - nor her relatives were told about the "inadequate" samples while she was still alive. Her family have now been given an undisclosed payout, with the trust apologising for its mistakes that had "devastating consequences". Ms Gleadell, from Cossington in Leicestershire, was diagnosed with cervical cancer two years prior to her death. It was, by that stage, too late to have surgery. Two cervical screening tests, carried out in 2008 and 2012, were misreported to her as negative. It meant that over a four-year period, she had been given false reassurance about her health when she was developing cervical cancer, and the opportunity to treat pre-cancerous cells passed. Ms Gleadell's sisters, Laura and Clare Gleadell, say their grief has been compounded by knowing that their sister's death was avoidable. Laura, 43, said: "Her death was preventable and that for us is ultimately really hard. "It would not have developed into cancer had she been recalled in either 2008 or 2012. "If she had had treatment for cell abnormalities before it even developed into cancer, she would not have died." Read full story Source: BBC News, 6 April 2025
  15. News Article
    Repeated failings in the way scans are read are leading to delays in cancer diagnosis, unnecessary operations and avoidable deaths, England’s Health Ombudsman has warned. Since publishing a report four years ago which highlighted mistakes in the way digital images are read and used as a diagnostic tool, the Parliamentary and Health Service Ombudsman (PHSO) has upheld or partly upheld more than 40 cases in which similar failings were found. The most common issues are doctors failing to identify an abnormality, scans not being carried out or delayed, and results not being properly followed up. Examples of the impact of these failings include a 10-month delay in cancer being diagnosed which significantly harmed the person’s chance of survival. In another case, serious pelvic sepsis was not identified which led to an avoidable death, and in a separate case, a missed ankle fracture led to an avoidable operation. The Ombudsman is calling for greater learning when things have gone wrong to prevent the same mistake being made. Read full story Source: PHSO, 20 March 2025
  16. News Article
    A woman whose mother died five years after a cancer misdiagnosis is calling for second opinions on oncology scans to be made mandatory. Louise Hickman, from Ipswich, was told in 2019 that a mass removed from her ovary was benign and that she would not require any further treatment. But in 2022, the “kind and caring mother” was diagnosed with ovarian cancer after she returned to Ipswich Hospital with worsening symptoms. Later tests confirmed her initial cyst found three years earlier had indeed been cancerous and in July 2024, she passed away, aged 47. Her daughter, Chloe, said she believes her mother’s outcome may have been different if she was correctly diagnosed in 2019, and is now campaigning to make it mandatory to have oncology scans checked by two experts. A report issued to Ms Hickman and her family by the East Suffolk and North Essex NHS Foundation Trust following her mum’s death accepted that the 2019 cyst should have been “adequately sampled and referred for an expert opinion” at the time. A clinical opinion included in the report also stated that the “missed diagnosis with delay in treatment caused significant harm”. She has launched a petition calling for the government to implement “Louise’s Law”, which would make it mandatory that benign oncology scans are sent for a second expert opinion. Read full story Source: The Independent, 19 March 2025
  17. News Article
    A coroner has issued a warning about the role of physician associates in NHS hospitals after a woman with severe abdominal problems was wrongly diagnosed as having a nosebleed and died four days later. The family of Pamela Marking, 77, were under the mistaken impression she had been seen by a doctor when she was examined in an emergency department, rather than a physician associate (PA) with far less training. Surrey assistant coroner Karen Henderson has written to 12 health leaders or bodies including the UK health secretary, Wes Streeting, and NHS England expressing concerns about the “limited training” PAs have and the lack of public understanding about their roles. In a prevention of future deaths report, Henderson said Marking was taken to East Surrey hospital in Redhill on 16 February last year after she vomited blood-stained fluid and had a tender abdomen. The coroner said the PA who saw her had “a lack of understanding of the significance of abdominal pain” and sent her home the same day. Marking deteriorated, returning to the hospital two days later. She underwent surgery for complications arising from a femoral hernia but died on 20 February 2024. Henderson said the PA had acted independently in the diagnosis, treatment, management and discharge of Marking without independent oversight by a medical practitioner. The coroner said: “Given their limited training and in the absence of any national or local recognised hospital training for physician associates once appointed, this gives rise to a concern they are working outside of their capabilities.” Read full story Source: The Guardian, 27 February 2025 Related reading on the hub: Physician associates: What are the patient safety issues? An interview with Asif Qasim Partha Kar: We need a pause to assess safety concerns surrounding Physician Associates Prevention of future deaths report: Susan Pollitt (8 August 2024)
  18. Event
    until
    Join Patients for Patient Safety US for 3 days of events centred around World Patient Safety Day (WPSD) 2024. PFPS US urges Americans impacted by missed or delayed diagnoses, bias or medical error to convene in Washington, DC for a Summit held September 15-17, 2024. The World Health Organization designates 17 September 17 as World Patient Safety Day, and WPSD 2024’s theme is Improving Diagnosis for Patient Safety. Find the full Summit event list at https://www.pfps.us/wpsd-2024, including: Sunday 15 September: Welcome reception and dinner at Johns Hopkins University Bloomberg Center to launch Project PIVOT, a national project identifying patient-prioritized outcomes and experiences and collaboration with patient organizations, US Department of Health and Human Services, Johns Hopkins University, Harvard Medical School and others. Monday 16 September: Participants visit Capitol Hill to urge Congressional leaders to ACT Now for patient safety, diagnostic safety and health equity solutions. ACT Now is PFPS US’s urgent request to leaders for Accountability, Coordination, and Transparency in health care. Later, PFPS US and AcademyHealth co-host a film premiere of The Pitch: The Next Generation of Patient Safety. From immersive tech to AI machine learning, innovations are finally making waves in medicine with the goal of safer health care. The Pitch gives a unique look at the American health care system’s ongoing challenge to embrace the next generation of patient safety. Tuesday 17 September, World Patient Safety Day: The March for Patient Safety begins at Freedom Plaza and ends with a ceremony on the US Capitol Lawn, where marchers will remember those whose lives have been lost to or impacted by preventable harm. Afterwards, PFPS US and the Bloomberg Center co-host a World Patient Safety Day Leadership Briefing with government leaders. Further information and to sign up
  19. Community Post
    Tuesday 17 September 2024. Another year, another World Patient Safety Day. This years theme “Improving diagnosis for patient safety”. Last years' report by the World Health Organization https://www.who.int/publications/i/item/9789240095458 first introduced the theme and talked about the need for multifaceted interventions rooted in systems thinking, human factors and active engagement of patients, their families, health workers and healthcare leaders. Improving healthcare processes that will result in improvements to diagnosis requires action at every level of the health system and looking at this years' calls to action https://www.who.int/campaigns/world-patient-safety-day/world-patient-safety-day-2024/calls-to-action leadership is both implied and front and centre. Focusing on these calls to action, here is what the campaign suggests individuals/entities across a range of settings can do to help improve patient safety in diagnosis. Patients, families and caregivers are - be informed, involved, and proactive in your diagnosis Be actively engaged in the diagnostic process and with your health care team: share accurate and comprehensive information about your symptoms and medical history; make sure you understand the diagnostic process, your illness’ or symptoms expected progression, and next steps; check your information is up-to-date, and keep track of your symptoms, medical visits, tests and treatments. Share your questions and concerns: don’t be afraid to ask questions; speak up, ask about alternative options or seek a second opinion if you need to; share your experiences and contribute to making diagnosis safer for others. Health workers providing clinical care - make diagnostic excellence integral to your daily practice Keep focussed on the person at the centre of the diagnosis: listen to your patient, ask them about their concerns and tailor the interventions to their needs; take a careful and thorough history and physical examination of your patient; talk openly and empathetically with your patients, and encourage them to ask questions. Leverage available technology, tools, and tests to reach a diagnosis. Be a good team player and contribute to a safe and collaborative professional environment, where information is shared in a timely manner. Keep learning: participate in regular training and seek feedback from your peers and patients; contribute a culture of continuous improvement by sharing best practices, and information about errors and near misses with peers. Healthcare facility leaders and managers - implement safer systems to improve diagnosis, support your clinical teams and empower patients Empower the health workforce through policy, culture and practice: ensure adequate staffing, resources and regular capacity development; make sure quality and well-maintained tests and technologies are available; implement and monitor the use of diagnostic safety guidelines, protocols and practices to ensure errors are minimised; promote a culture of continuous learning and safety, and take action to address problem areas; establish a conducive, collaborative and safe work environment free from distractions. Continually seek feedback from patients and their families and reserve space for advocates on advisory bodies. Celebrate diagnostic excellence within your teams. Policy-makers and programme managers - champion diagnostic excellence in health policy Prioritise patient safety in policy, legislation and regulation: ensure that appropriate guidelines and protocols to support diagnostic processes exist at a national level and are implemented; provide the necessary budget, staff, training and access to tools and technologies for national health systems. Establish national collaboration mechanisms to sustainably engage stakeholders. Promote accountability through monitoring and evaluation mechanisms, and ensure health leadership prioritize transparency. Set up national knowledge-sharing systems and encourage continuous learning. Invest in research into diagnostic errors, patient harm and the development of diagnostic tools and technologies. Patient organizations and civil society - advocate for quality and safe diagnosis Champion diagnostic safety in health policy and practice: work with patients, policy-makers and health care leaders to build health systems that deliver correct and timely diagnosis; facilitate patient advocacy and support their role in promoting and improving diagnostic safety; work with policy-makers, academics, health care leaders, health workers and patients to help identify areas for improvement. Contribute to the development of educational and training resources for health workers and patients. Diagnostics and medical devices’ regulators, manufacturers, innovators and managers - innovate for smart solutions and diagnostic excellence Drive research and development for diagnostic tools and technologies. Ensure diagnostic solutions meet the highest standards of safety, quality, and reliability. Create user-friendly products and instructions and provide regular training for health workers and patients. Collaborate with patients, health workers and health care leaders to build products tailored to the needs of end-users. I'm a strong believer in the power of campaigns. They act as a tool to raise awareness on important matters and trigger action that will result in change and improvement and there is evidence that they can have an impact on patient outcome. Before the end of 2024 there will be many more awareness days and weeks all of which will use campaigning to get their messages across in the noisy world of health care. It will be interesting to see the evaluation of WPSD 2024. More on this in due course.
  20. Community Post
    Have you or someone you know been affected by a: delayed diagnosis incorrect diagnosis missed diagnosis? Errors can happen at every stage of the diagnostic process and can happen in all healthcare settings. In some circumstances the impact is life-changing. If you have insights to share around diagnostic error and the impact on patient safety, please comment below (sign up first here, for free). Or you can contact us directly at [email protected]. This post has been published as part of our World Patient Safety Day activity, with the 2024 theme of Improving diagnosis for patient safety. #WPSD, #WorldPatientSafetyDay, World Patient Safety Day 2024
  21. Content Article
    This debate was requested by Barbara Keeley MP of Worsley and Eccles South, following the death of Emily Chesterton, the daughter of her constituents Marion and Brendan Chesterton. Emily died in November 2022 after suffering a pulmonary embolism. She was just 30 years old when she died. The conclusion of the coroner was: “Emily Chesterton died from a pulmonary embolism, a natural cause of death. She attended her general practitioner surgery on the mornings of 31 October and 7 November 2022 with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived.”
  22. Content Article
    Most healthcare organisations (HCOs) find diagnostic errors hard to address. Singh et al. developed a checklist (the Safer Dx Checklist) of 10 high-priority safety practices HCOs can use to conduct a proactive risk assessment to address diagnostic error.
  23. Content Article
    Calibration, defined as alignment between a person’s diagnostic accuracy and their confidence in that accuracy, is an essential component of diagnostic excellence. Miscalibration—the misalignment between a person’s diagnostic accuracy and their confidence in that accuracy—can manifest as either overconfidence or underconfidence and can have serious consequences for patient diagnosis. This resource about calibration from the US Agency for Healthcare Research and Quality (AHRQ) is primarily aimed at individual clinicians whose scope of practice includes diagnosis. It focuses on processes involved in making a diagnosis and the outcome of giving an explanatory label to patients after these processes unfold.
  24. Content Article
    Diagnostic error research has largely focused on individual clinicians’ decision making and system design, largely overlooking information from patients. This article in the journal Health Affairs analysed a unique data source of patient- and family-reported error narratives to explore factors that contribute to diagnostic errors. The analysis identified 224 instances of behavioural and interpersonal factors that reflected unprofessional clinician behaviour, including ignoring patients’ knowledge, disrespecting patients, failing to communicate and manipulation or deception. The authors concluded that patients’ perspectives can lead to a more comprehensive understanding of why diagnostic errors occur and help develop strategies for mitigation. They argue that health systems should develop and implement formal programs to collect patients’ experiences with the diagnostic process and use these data to promote an organisational culture that strives to reduce harm from diagnostic error.
  25. Content Article
    Most people experience a diagnostic error at least once in their lifetime. Patients’ experiences with their diagnosis could provide important insights when setting research priorities to reduce diagnostic error. The objective of this study from Zwaan et al. was to engage patients in research agenda setting for improving diagnosis. Patients were involved in generating, discussing, prioritising, and ranking of research questions for diagnostic error reduction. Highlights Patients identified diagnosis research priorities complementary to researchers. Patients prioritised research on care coordination, transitions and implicit bias. Findings can inform research funding to reduce diagnostic error.

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