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David E. Newman-Toker, MD, PhD; Peter J. Pronovost, MD, PhD

JAMA. 2009;301(10):1060-1062.

	Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.

During the past decade, awareness and understanding of medical errors have expanded rapidly, with an energetic patient safety movement promoting safer health care through "systems" solutions. Efforts have focused on translating evidence into practice, mitigating hazards from therapies, and improving culture and communication. Diagnostic errors have received relatively little attention. Although the science of error measurement is underdeveloped, diagnostic errors are an important source of preventable harm.^1-3 In this Commentary, we offer definitions for diagnostic error and misdiagnosis-related harm, present an overview of the magnitude of diagnostic errors, and give suggestions for how research can mature.

Distinguishing Errors From Harms

In considering diagnostic errors, it is important to distinguish between the error (a process) and the resulting harm (an outcome). Diagnostic error can be defined as a diagnosis that is missed, wrong, or delayed, as detected by some subsequent definitive test or finding.¹ However, . . . [Full Text of this Article]

Develop Systems Solutions to Cognitive Problems

Create Actionable Categories of Errors Based on Context Rather Than Cause

Emphasize Misdiagnosis-Related Harm Rather Than Diagnostic Error

Build Workflow-Sensitive Solutions

Focus on Comparative and Cost-effectiveness

Author Affiliations: Departments of Neurology (Dr Newman-Toker) and Anesthesiology and Critical Care (Dr Pronovost), Johns Hopkins University School of Medicine, Baltimore, Maryland.

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