Partners in Safety

Engaging Patients as Partners in Reducing Diagnostic Error

This week, the National Patient Safety Foundation leads Patient Safety Awareness Week, a time to recognize and celebrate the many advances in patient safety over the years and the vast amount of work currently being done. This year’s theme urges patients to Navigate Your Health…Safely, which we believe can only be done when patients and families are encouraged to take an active role in their care and are embraced as important members of the health care team.


A patient’s health journey often starts with diagnosis, and usually that process is done efficiently and accurately. Yet missed diagnoses occur often enough to be a serious concern in health care. Experts estimate that up to one in every 10 diagnoses is wrong, delayed, or missed completely, and that, collectively, diagnostic errors may account for 40,000 to 80,000 deaths per year in the US.

For Patient Safety Awareness Week 2014, NPSF has teamed up with the Society to Improve Diagnosis in Medicine (SIDM) to develop and disseminate educational materials for clinicians, health systems, and patients and consumers specifically related to better understanding and prevention of diagnostic errors.

While diagnosis often involves some element of uncertainty, there are many ways that stronger patient engagement can help reduce errors in the diagnostic process.

Improving Communication

Patients need to feel empowered to ask questions until they fully understand both their condition and the plan of care. At NPSF, we encourage patients to use the Ask Me 3 series of questions with their care providers. This can only be successful, however, if clinicians encourage and respond to patients’ questions. While most clinicians today work under time pressures, taking the time to answer a patient’s questions—and make sure they understand—can stave off an error down the line.

Closing the Loop

Patients should never assume that “no news is good news.” If a lab test or imaging study is ordered, clinicians and patients should discuss in advance how the results will be conveyed, and approximately when. This, of course, loops back to communication—two-way communication is crucial to making sure that important findings do not go overlooked.

Getting Screened

The US Preventive Services Task Force sets recommendations for routine screening tests. Patients can visit to find out which tests are most appropriate for them, their children, or other loved ones.

Keeping Records

Although many hospitals and physician practices are using electronic health records, it is good practice for patients to also keep records of their own. Patients who keep track of the medications they take, illnesses they’ve been treated for, and any hospitalizations or surgeries, are much more prepared to be a good reporter when talking with their clinicians.

We will not solve the issue of diagnostic error this week, or even this year, but clinicians who want to learn more about this issue or patients who want to know how to be more involved in their care can visit the NPSF website to reference materials specially prepared for Patient Safety Awareness Week 2014.



Tejal K. Gandhi, MD, MPH, CPPS Tejal K. Gandhi, MD, MPH, CPPS, is chief clinical and safety officer at the Institute for Healthcare Improvement (IHI). Previously, she was president and CEO of the National Patient Safety Foundation, which merged with IHI in May 2017. An internist and associate professor of medicine at Harvard Medical School, Gandhi was formerly the chief quality and safety officer at Partners Healthcare in Boston, Massachusetts. In 2009 she received the John M. Eisenberg Patient Safety and Quality Award for her contributions to understanding the epidemiology and possible prevention strategies for medical errors in the outpatient setting.

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1 Comment

  • At your last recommendation, Dr. Gandhi, “good practice for patients to also keep records of their own” could have mentioned setting up a PHR.

    Records can be on paper organized for easy retrieval or could be a personal health record (PHR) “in the cloud” with a firm such as

    –iTriage app My iTriage (

    –Microsoft HealthVault ( or

    –a hospital patient portal such as MyChart.

    In addition to storing medical data, the PHR could incorporate activity tracking data, disease prevention information and nutrition / meal planning guidance. Patients, individuals, caregivers and others can put a PHR to work improving self-healthcare 9see the Google+ community) and their quality of life.

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