| HIDDEN IN PLAIN SIGHT | Exposing the Drivers of Diagnostic Error A DOSE OF INSIGHT ® Coverys | DIAGNOSTIC ERROR PAST INITIATIVES & PRESENT STATE To err is human. This is not just an accepted truth – it’s also part of the title of the groundbreaking 1999 report1 from the Institute of Medicine. The report found that roughly 98,000 people died every year due to medical errors in hospitals. Widespread media attention followed, sensationalizing the topic by focusing on who was to blame. While the 1999 report put a spotlight on the topic of medical error, diagnostic error did not receive specific attention until the same organization released their 2015 report2, “Improving Diagnosis in Healthcare.” This report revealed that most patients experienced at least one diagnostic error in their lifetime, with sometimes serious consequences. Prior to this report, diagnostic error was largely unappreciated as a major cause of medical error. Over time, as we’ve expanded our understanding of medical error, the focus has shifted from who to blame to deciphering why it occurs and promoting widespread acceptance that systems and interactions between systems and humans are key drivers of circumstances that can result in diagnostic error. Many organizations have published guidance to help reduce errors related to diagnosis. For example, The Leapfrog Group3 introduced a national initiative to identify best practices, create a roadmap for health systems, and survey hospitals’ progress. Others, such as Agency for Healthcare Research and Quality (AHRQ), expanded the TeamSTEPPS4 principles to include a module on diagnosis, and research published by The Joint Commission5 led to a checklist of 10 practices for diagnostic error reduction. Despite these ongoing efforts, the challenge of diagnostic error persists. A 2019 study6 reported that 795,000 Americans die or become permanently disabled due to misdiagnosis each year. While the high-level clinical trends in malpractice events have remained unchanged, we now have a better understanding of contributing risk factors and mitigation strategies to reduce the incidence of diagnostic error. ( 2 ) What is diagnostic error? Diagnostic error is the failure to either establish an accurate and timely explanation of the patient’s health problem(s) or communicate that explanation to the patient. -National Academy of Medicine