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Setting the record straight on measuring diagnostic errors. Reply to: 'Bad assumptions on primary care diagnostic errors’ by Dr Richard Young
  1. Hardeep Singh1,
  2. Dean F Sittig2
  1. 1 Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
  2. 2 University of Texas School of Biomedical Informatics and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, Texas, USA
  1. Correspondence to Dr Hardeep Singh, VA Medical Center (152), 2002 Holcombe Blvd, Houston, TX 77030, USA; hardeeps{at}

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Upon reading Dr Young's letter,1 we felt we should have prefaced our article by quoting Box and Draper who wrote in their classic 1987 book,2 ‘all models are wrong, but some are useful’. Our goal in developing a new model for safer diagnosis in healthcare was to illustrate the myriad, complex, socio-technical issues and their interactions within a complex adaptive healthcare system that must be considered when attempting to define and measure errors in the diagnostic process.3 While the comments by Dr Young provide one clinician's view of the complexity and breadth of diagnostic error, we welcome an opportunity to respond to clarify the premise of the Safer Dx framework. Dr Young is concerned that we presented the problem of diagnostic error as black and white rather than considering day-to-day realities of patient care that includes vast uncertainties in data collection, interpretation and synthesis. He further asserts that the concept of delayed diagnosis in primary care needs to be severely curtailed and that except for straightforward cases of blatant negligence we should not even use the language of delayed or missed diagnoses. Lastly, he writes that physicians might be vilified for missed or delayed diagnosis even though they made appropriate and informed decisions including watchful waiting when the diagnosis was not yet clear. In our response below, we attempt to lay many of these concerns to rest and provide further information on diagnostic error reduction research. We believe the concepts that we clarify herein will reassure hardworking primary care clinicians on the frontlines that the major goal of our framework is to promote the understanding and reduction of preventable diagnostic harm to our patients and not assign blame. Moreover, the rationale for the framework and our response applies to all clinicians, not just those in primary care. …

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  • Twitter Follow Dean Sittig at @DeanSittig and Hardeep Singh at @HardeepSinghMD

  • Funding HS was supported by the VA Health Services Research and Development Service (CRE 12-033; Presidential Early Career Award for Scientists and Engineers USA 14-274), the VA National Center for Patient Safety and the Agency for Health Care Research and Quality (R01HS022087). This work was supported in part by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413).

  • Disclaimer The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the University of Texas.

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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