A growing body of evidence shows that diagnostic errors are the most common, catastrophic and costly of all medical errors. They are difficult to identify and often go unrecognized until it is too late. The science of diagnostic safety and quality remains underdeveloped and underfunded.
The center, which is the first of its kind in the world, provides a unique, collaborative, transdisciplinary environment for clinicians, researchers, engineers and data experts to work together to tackle the challenges of medical misdiagnosis. The Armstrong Institute Center for Diagnostic Excellence was borne out of a need to address this dangerous and costly problem. Housed in the Armstrong Institute and led by Dr. David Newman-Toker, a world leader in diagnostic error research, the center plans to eliminate preventable patient harms from diagnostic errors.
The Impact of Diagnostic Errors
Diagnostic errors will likely touch each of us in our lifetimes.
- An estimated 12 million Americans are affected each year, and perhaps one-third are harmed as a result.
- These errors may account for 40,000 to 80,000 preventable deaths annually in U.S. hospitals.
Though appropriate use of diagnostic tests can help combat diagnostic errors and add value to patient-centered care, more testing alone will not deliver diagnostic value. The costs of advanced diagnostic tests are spiraling upward faster than any sector of the health care industry, and inappropriate overuse of diagnostic tests will only multiply the costs. Diagnostic error and diagnostic test overuse are global problems requiring bold, innovative solutions.
The center’s first signature initiative will be to tackle stroke misdiagnosis throughout Johns Hopkins Hospital emergency departments. Future initiatives will address sepsis and cancer diagnosis. Together, the initiatives will address the “big three” that account for at least one-third of all diagnostic errors and likely more than half of the harms from diagnostic errors.
Why Stroke Misdiagnosis?
- More than 1 million people in the United States suffer a stroke or transient ischemic attack (TIA, or pre-stroke) every year, with about three in four being first-time strokes.
- Stroke is the fifth leading cause of death in the United States, killing nearly 130,000 people a year, or one every 4 minutes. That’s one in every 20 deaths.
- Stroke is a leading cause of long-term disability and among the most preventable. Rapid access to treatment reduces brain injury, prevents complications, avoids major stroke after minor stroke and improves patient outcomes.
- Minor, early strokes are currently missed 30 to 50 percent of the time, often when patients have common symptoms — dizziness, vertigo, headaches — that are diagnosed as a less serious problem.
- Timely diagnosis leading to prompt, correct treatments can prevent death and disability.
Currently, a lack of prompt treatment leads to preventable harms because patients suffer major strokes after undiagnosed minor strokes. Our target is to cut harms from missed strokes in half within five years.
How will we accomplish this?
We will train providers in the latest bedside diagnostic techniques using state-of-the art educational simulations. These will include screen-based case simulations for cognitive skills as well as novel partial task trainers for psychomotor skills. Our simulations will be driven by real-world data from our ongoing AVERT clinical trial (Clinical Trials.gov NCT02483429).
We will launch the Comprehensive Unit-based Safety Program to Improve Diagnosis (CUSPID). This adapted version of the highly successful culture change framework known as CUSP will specifically target achieving diagnostic excellence through local, grass-roots efforts that identify diagnostic error problems, determine causes and envision solutions.
We will apply cutting edge technologies to enhance early stroke recognition in the Johns Hopkins Health System’s emergency departments. Portable diagnostic devices will facilitate the use of telemedicine to deliver immediate expertise to the bedside. Automation of this process, currently underway in our AVERT clinical trial (Clinical Trials.gov NCT02483429), will further enhance accuracy and efficiency. These projects will increase quality and decrease costs.
We will develop operational measures of diagnostic accuracy, error and value for stroke. Our first-generation Diagnostic Performance Dashboard will monitor harms from missed stroke and process failures, enabling feedback to providers and ensuring accountability at all levels. We will conduct economic analyses of stroke interventions, identifying the highest value solutions.
Newly-released AHRQ Effective Healthcare Program report authored by the Johns Hopkins University Evidence-based Practice Center and experts at the Johns Hopkins Armstrong Institute Center for Diagnostic Excellence synthesizes 20 years of medical research, providing critical new insights into the frequency, distribution, and causes of diagnostic error and associated harms in the emergency department.
Want to join a core group? Interested in becoming a partner? Have ideas for new initiatives? Contact us at DXCenter@jhu.edu.
Annual Diagnostic Excellence Summit
The Annual Diagnostic Excellence Summit features expert speakers and small group discussions focused on ways to envision keeping diagnosis human in the digital age.
News and Publications
The Armstrong Institute Center for Diagnostic Excellence provides resources for patients, providers, scientists and administrators working together to tackle the challenges of misdiagnosis. Regularly featured in national media, the following is a collection of the outlets where faculty and staff members help advance public knowledge on ways to address the problem of diagnostic errors.
- Your diagnosis was wrong. Could doctor bias have been a factor? (Washington Post, November 18, 2019)
- Diagnosis errors account for one-third of severe harm malpractice claims (Modern Healthcare, July 11, 2019)
- Why Public Reporting of Diagnostic Errors Might Come Sooner than You Think (Voices for Safer Care, June 11, 2018)
- A Method to Measure Diagnostic Errors Could Be Key to Preventing Disability and Death from Misdiagnosis, (Science Daily, January 22, 2018)
- "Johns Hopkins Researchers Use Big Data Analytics to Target Diagnostic Errors, Improve Quality", (Fierce Healthcare, January 23, 2018)
- "Johns Hopkins to Study How to Better Diagnose Disease", (Baltimore Sun, November 1, 2016)
- “Fighting Misdiagnosis”, (Dome, November 2016)
- “Eyeing a New Way to Diagnose Stroke” (Hopkins Medicine, Fall 2016)
- “The Brain Tumor Is Benign, but Threats Remain” (The New York Times, April 27, 2016)
- “Diagnostic Errors Are Lead Cause of Medical Liability Payouts” (AMA Medical News, May 6, 2013)
- “Why Doctors Are Sued” (The New York Times, April 29, 2013)
- “Adding Up Diagnosis Errors” (Wall Street Journal, April 24, 2013)
- “Goggles-and-Laptop Device Might Help Detect Some Strokes” (Los Angeles Times, March 5, 2013)
- “5 Most Commonly Misdiagnosed Conditions in the ICU” (American Association of Retired Persons, Nov. 16, 2012)
- “Eye Movement Exam More Accurate Than MRI in Stroke Prediction” (HealthCare Business, Sept. 29, 2009)
- “Misdiagnosis and Wrong Diagnosis by Doctors Cause 40,000 Deaths Each Year” (The Legal Examiner, Aug. 16, 2009)
- Medical Misdiagnosis (America Tonight, Al Jazeera Network, minutes 44–55, September 2016)
- Stroke of Genius: New Device Could Save Lives and Money (CBS This Morning, March 6, 2013)
- Maryland Commerce Supports Research Professorships at Eight Higher Education Institutions, October 19, 2021
- More than $14 million in research grants awarded for health technology solutions focused on heart and brain health, including special projects related to COVID-19 and CVD April 4, 2020
- Johns Hopkins Medicine Researchers Identify Health Conditions Likely to be MisDiagnosed, July 11, 2019
- A Method to Measure Diagnostic Errors from Big Data Could be Key to Preventing Disability and Death from Misdiagnosis, January 22, 2018
- David Newman-Toker Named President-Elect of the Society to Improve Diagnosis in Medicine, October 11, 2017
- Johns Hopkins Opens New Center to Reduce Diagnostic Errors, October 31, 2016
- Diagnostic Errors More Common, Costly and Harmful Than Treatment Mistakes, April 23, 2013
- Is It a Stroke or Benign Dizziness? A Simple Bedside Test Can Tell, March 5, 2013
- Johns Hopkins Patient Safety Team Finds Diagnostic ‘Fatal Flaws’ in the ICU May Account for as Many Annual Deaths as Breast Cancer, August 27, 2012
- Cheap, Quick Bedside ‘Eye Movement’ Exam Outperforms MRI for Diagnosing Stroke in Patients with Dizziness, September 18, 2009
- Diagnostic Errors: The New Focus of Patient Safety Experts, March 11, 2009
- Preventing a Mis-Diagnosis (A Woman's Journey)
- Medical Misdiagnosis: More Common Than You Think (WYPR, national NPR affiliate, October 31, 2017)
- Common Symptoms, Uncommon Causes: Reducing Misdiagnosis on the Front Lines (Armstrong Institute blog, November 3, 2016)
- How Teamwork Can Reduce Missed Diagnoses (Armstrong Institute blog, June 6, 2016)
- “Missed Strokes” (Johns Hopkins Health Newsfeed/national NPR affiliates, Oct. 19, 2015)
- “Stroke Miss” (Johns Hopkins Health Newsfeed/national NPR affiliates, May 13, 2014)
- Diagnostic performance dashboards: tracking diagnostic errors using big data, BMJ Qual Saf Published Online First: 17 March 2018. doi: 10.1136/bmjqs-2018-007945, Mane KK, Rubenstein KB, Nassery N, et al
- ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging, The Official Journal of the American Academy of Neurology, 2017 March. Alexander Andrea Tarnutzer, MD, Seung-Han Lee, MD, Karen A. Robinson, PhD, Zheyu Wang, PhD, Jonathan A. Edlow, MD* and David E. Newman-Toker, MD, PhD*
- Diagnostic errors: the next frontier for patient safety. JAMA. 2009 Mar; 301(10):1060-62. Newman-Toker DE, Pronovost PJ.
- A unified conceptual model for diagnostic errors: underdiagnosis, overdiagnosis, and misdiagnosis. Diagnosis. 2014 1(1): 43–48. Newman-Toker DE.
- How much diagnostic safety can we afford… and how should we decide? A health economics perspective. BMJ Qual Saf. 2013 22 Suppl 2 (2013), ii11-ii20. Newman-Toker DE, McDonald KM, Meltzer DO.
- 25-year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank. BMJ Quality and Safety. 2013 Aug;22(8):672-80. Saber Tehrani AS, Lee HW, Mathews SC, Shore A, Makary M, Pronovost PJ, Newman-Toker DE.
- Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics. Diagnosis. 2015 Feb;2(1):29-40. Moy E, Barrett M, Coffey R, Hines A, Newman-Toker DE.
- Missed diagnosis of stroke in the ED: a cross-sectional analysis of a large population-based sample. Diagnosis. 2014 Apr;1(2):155-166. Newman-Toker DE, Moy E, Valente E, Coffey R, Hines A.
- Missed stroke in acute vertigo and dizziness: It is time for action, not debate. Ann Neurol. 2016 Jan;79(1):27-31. Newman-Toker DE.
- HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor exam more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-3510. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE.
- Establishment of a new prostate cancer multidisciplinary clinic: Format and initial experience. Prostate. 2015 Feb;75(2):191-9. doi: 10.1002/pros.22904. Epub 2014 Oct 13. Sundi D, Cohen JE, Cole AP, Neuman BP, Cooper J, Faisal FA, Ross AE, Schaeffer EM.
- Establishment of a new prostate cancer multidisciplinary clinic: Format and initial experience. Sundi D, Cohen JE, Cole AP, Neuman BP, Cooper J, Faisal FA, Ross AE, Schaeffer EM.
- Impact of a single-day multidisciplinary clinic on the management of patients with liver tumors. Current Oncology. 2013; 20: e123-e131. Zhang J, Mavros MN, Cosgrove D, et al.
- Multidisciplinary Clinic in the Management of Hepatocellular Carcinoma. Annals of Surgical Oncology. 2014; 21: 1059-1061. Soares KC, Cosgrove DC, Herman JM, Pawlik TM.
- Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer. Annals of Surgical Oncology. 2008; 15:2081-2088. Pawlik TM, Laheru D, Hruban RH, et al.