Impact of Health Systems Research on Diagnostic Errors and Patient Safety
March 5, 2025
Takeaway: Diagnostic errors in healthcare can have adverse consequences for patients, clinicians, and health systems. The work and research findings of HSR investigator Hardeep Singh, MD, MPH, and his team address diagnostic errors and advance patient safety and care quality by influencing policies in VA and around the world. Prominent healthcare organizations and agencies—including the World Health Organization, the Centers for Disease Control and Prevention, and the Centers for Medicare & Medicaid Services—have cited Dr. Singh’s work in their reports and policy statements.
In a 2015 report, the National Academies of Sciences, Engineering, and Medicine defined diagnostic errors in healthcare as the failure to establish an accurate and timely explanation of the patient’s health problem(s) or communicate that explanation to the patient. [1]
Background
Diagnostic errors in healthcare can have adverse consequences for patients, clinicians, and health systems.[2] Yet errors such as preventable delays in diagnosis or incorrectly diagnosed conditions occur across all levels of care, from primary care to hospital care, [3] and can lead to delayed or unnecessary treatment.
Today, diagnostic errors are considered a high-priority, multifaceted problem that involves many common conditions. [4] Much of the foundational research in this area has been spearheaded by Hardeep Singh, MD, MPH, a research scientist at HSR’s Center for Innovations in Quality, Effectiveness and Safety (IQuESt), who has been funded by VA and other agencies for nearly two decades to identify ways to reduce diagnostic errors. The findings of these studies have influenced patient safety and care quality not just within VA but around the world, as they have been instrumental in shaping U.S. national policy and global practice improvement initiatives.
Impacts on Policy, Practice, and Patients
- Dr. Singh’s work on defining and measuring the problem of diagnostic errors significantly influenced the 2015 National Academies report “Improving Diagnosis in Health Care,” which cited 32 papers he authored.
- Dr. Singh co-led and collaborated with VA’s Office of Primary Care on a national policy (VHA Directive 1088) related to communication of test results. Based on this policy and Dr. Singh’s research, VA’s Office of Performance Measurement developed new performance indicators of timely communication of test results along with quality measurement guidance for data collection through the External Peer Review Program. This initiative is informing a measure for the Strategic Analytics for Improvement and Learning Value Model.
- Two publications led by Dr. Singh informed the President’s Council of Advisors on Science and Technology 2023 report “A Transformational Effort on Patient Safety,” which outlined recommendations to advance the nation’s commitment to supporting robust safety solutions for patients and the healthcare workforce.
- The Centers for Medicare & Medicaid Services (CMS) cited four publications co-authored by Dr. Singh in a collection of 2024 policy changes.
- The Centers for Disease Control and Prevention (CDC) cited 13 publications co-authored by Dr. Singh in its 2024 publication “Core Elements of Hospital Diagnostic Excellence,” which was created in collaboration with the Agency for Healthcare Research and Quality (AHRQ) and CMS. The document provides a summary of practices that can be used to improve the diagnostic process.
- The World Health Organization (WHO) cited six papers co-authored by Dr. Singh in its “Global Patient Safety Report 2024.” Additionally, Dr. Singh co-led several working groups for WHO’s “Global Patient Safety Action Plan 2021–2030” and served on their writing committee. The action plan was adopted by the World Health Assembly and will provide policy, strategic guidance, and technical support to all countries on how to prevent avoidable harm in healthcare. Dr. Singh also led the WHO report “Implications of the COVID-19 Pandemic for Patient Safety: A Rapid Review” and was an invited member of the WHO Steering Committee and Planning Group for World Patient Safety Day 2024.
- Dr. Singh, Dean Sittig, PhD, of UTHealth School of Biomedical Informatics, and their teams developed the “Safety Assurance Factors for EHR Resilience (SAFER) Guides,” which all U.S. hospitals use to assess patient safety issues related to health IT. [5] Beginning in 2022, CMS required all U.S. hospitals eligible for reimbursement to attest to using these guides annually. Updated versions of the guides were released by the Office of the National Coordinator for Health Information Technology in 2025. They include:
- Organizational Responsibilities
- High Priority Practices
- Patient Identification
- Clinician Communication
- Test Results Reporting and Follow-Up
- Computerized Provider Order Entry with Decision Support
- System Configuration
- Contingency Planning
- Dr. Singh and his team, in collaboration with the Institute for Healthcare Improvement (IHI), created “The Safer Dx Checklist: 10 High-Priority Organizational Practices for Diagnostic Excellence” to inform healthcare organizational leaders about 10 actionable steps they can take to pursue high reliability in diagnostic safety. Working with AHRQ, they also developed resources such as Measure Dx and Calibrate Dx to improve diagnosis at an organizational or clinician level.
- Dr. Singh has served on a variety of expert panels for national and international organizations, including the CDC, IHI, CMS, AHRQ, National Quality Forum, National Academy of Medicine, and The Leapfrog Group. He was on the panel that developed the CMS Patient Safety Structural Measure, a requirement as of 2025 for all U.S. hospitals that participate in the Hospital Inpatient Quality Reporting program.
Hardeep Singh, MD, MPH
“Diagnostic errors are now on the world stage. Our multidisciplinary team not only made scientific advances but also developed actionable strategies, tools, and resources. Now, it’s time to implement these actions to transform healthcare delivery systems, support clinicians and their care teams, and engage patients to reduce preventable harm from diagnostic errors.”—Hardeep Singh, MD, MPH
Partners
[1] Front Matter | Improving Diagnosis in Health Care | The National Academies Press
[2] Improving Diagnosis in Health Care — The Next Imperative for Patient Safety | New England Journal of Medicine
[3] The Path to Improve Diagnosis and Reduce Diagnostic Error - Improving Diagnosis in Health Care - NCBI Bookshelf
[4] The global burden of diagnostic errors in primary care - PubMed
[5] https://pubmed.ncbi.nlm.nih.gov/35129591/
