Preventing Patient Harm and Death from Diagnostic Errors: New Leapfrog Report Identifies 29 Recommended Practices that Hospitals Should Implement Now

July 28, 2022

The Leapfrog Group, an independent national watchdog organization of employers and other purchasers focused on health care safety, today released the report Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals. This landmark report is the result of an intensive year-long effort bringing together the nation’s leading experts on diagnostic excellence, including physicians, nurses, patients, health plans, and employers. Together, the multi-stakeholder group reviewed the evidence and identified 29 evidence-based actions hospitals can implement now to protect patients from harm or death due to diagnostic errors.

Diagnostic errors contribute to 40,000-80,000 deaths a year, with over 250,000 Americans experiencing a diagnostic error in hospitals. This includes delayed, wrong, and missed diagnoses, and those that are not effectively communicated to the patient. The report is the first step in Leapfrog’s longer term initiative, Recognizing Excellence in Diagnosis, which aims to rate hospitals and publicly report on their diagnostic excellence in the future. The initiative is funded by the Gordon and Betty Moore Foundation.

Leapfrog will use practices from the report issued today and survey hospitals on their current implementation status via a national pilot in fall 2022. The feedback collected from hospitals during the pilot will be used to develop a new section on the Leapfrog Hospital Survey slated for launch in 2024. The Society to Improve Diagnosis in Medicine (SIDM), a key partner in this initiative, was a leading stakeholder in identifying the practice recommendations and will develop tools and training materials to support hospitals in implementing the practices outlined in the report.

For each recommended practice, the report includes descriptions and resources to help hospitals implement the practice. The report also offers guidance to employers, purchasers, and patient advocates to motivate hospital action. Featured practices in the report include:

  • Making it easy for patients and family caregivers to report their diagnostic errors and concerns to the hospital
  • Implementing “closed-loop” communication to ensure that test results are reviewed by the ordering clinician and communicated to the patient on a timely basis
  • Convening a multidisciplinary team to implement hospital-wide diagnostic quality and safety programs, including the emergency department

“Clinicians and hospital leaders tell us they know diagnostic errors are harming too many patients, but they are less clear on how to fix the problem,” said Leah Binder, Leapfrog president and CEO. “Thanks to the incredible leadership of the multi-stakeholder group Leapfrog has convened, hospitals now have clarity on the steps to take. The faster hospitals act, the more lives they can save.”

In 2021, Leapfrog convened the nation’s leading experts on diagnostic excellence in a national advisory group to help evaluate existing practices in hospitals to improve diagnostic safety and quality and to develop this first-of-its-kind report. Leading experts include Hardeep Singh, MD, MPH, a patient safety researcher at Center for Innovations in Quality, Effectiveness and Safety (IQuESt) based at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston; Mark L. Graber, MD, FACP, SIDM founder and president emeritus; and a research team led by Matt Austin, PhD, associate professor, Johns Hopkins Armstrong Institute for Patient Safety and Quality. The National Advisory Group includes a diverse group of physicians, nurses, other clinicians with expertise in diagnosis and performance analysis, employers, health plans, and consumer advocates.

Hospitals interested in volunteering for the national pilot survey in 2022 should contact the Leapfrog Help Desk. Follow our progress and get the latest information on our website.

About The Leapfrog Group
Founded in 2000 by large employers and other purchasers, The Leapfrog Group is a national nonprofit organization driving a movement for giant leaps for patient safety. The flagship Leapfrog Hospital Survey and new Leapfrog Ambulatory Surgery Center (ASC) Survey collect and transparently report hospital and ASC performance, empowering purchasers to find the highest-value care and giving consumers the lifesaving information they need to make informed decisions. The Leapfrog Hospital Safety Grade, Leapfrog's other main initiative, assigns letter grades to hospitals based on their record of patient safety, helping consumers protect themselves and their families from errors, injuries, accidents, and infections. For more, follow us on Twitter and Facebook, and sign up for our newsletter.

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