Special Emphasis Notice (SEN): AHRQ Announces Interest in Research on Diagnostic Errors in Ambulatory Care Settings

Notice Number: NOT-HS-08-002

Key Dates
Release Date:  October 25, 2007

Issued by
Agency for Healthcare Research and Quality (AHRQ)

The mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans.  AHRQ achieves this mission by supporting a broad program of health services research and by working with partners to promote improvements in clinical and health systems practices that benefit patients.

In FY 2008, AHRQ intends to support research designed to gain a better understanding of the incidence, cost, determinants, and strategies for preventing or mitigating diagnostic errors (i.e., misdiagnosis, missed diagnosis, delayed diagnosis) in ambulatory care settings.  Note that for the purposes of this Special Emphasis Notice, ambulatory care refers to health care provided in emergency departments; clinicians’ offices and practices, both large and small; outpatient clinics; community health centers; urgent care centers, and ambulatory surgery centers.  Researchers from non-ambulatory settings with a strong interest in fostering safe, high quality ambulatory care and transitions are welcome to apply, but must do so in partnership with an ambulatory care organization.  In particular, a focus on transitions between ambulatory care, home care, and nursing homes is critical to the success of ambulatory care for many elderly and chronically ill populations.

Diagnostic error comprises a notable and costly fraction of all medical errors and has resulted in devastating consequences for patients, families, and health care professionals.  Diagnostic error encompasses a broad array of factors including cognitive, systems, education, training, setting-of-care, disease-specific, and domain-specific issues.  Examples of cognitive issues include flawed reasoning, incomplete knowledge, faulty information gathering or interpretation, and inappropriate use of decision-making heuristics (i.e., cognitive shortcuts used in decision making that do not always hold true).  Systems-related examples reflect production pressures and high patient volumes, flawed workflow process design and implementation, lack of standardized methods and processes, group think, authority gradients, misaligned payment incentives, and ineffective or faulty communication channels.  Examples of provider training and education issues involve pattern recognition, lack of guidelines for assessing diagnostic competency, and Bayesian analysis.  Performing and interpreting diagnostic tests may be more problematic in certain settings such as emergency departments, with certain diseases or conditions such as cancer or myocardial infarctions, and with certain patient characteristics that can include language, health literacy, incomplete history, and lack of patient insight for selected conditions (e.g., mental health diagnoses).  Laboratory factors may include technology issues and specimen readings.  These are just a few of the areas of vulnerability and the interdependencies that may exist and lead to diagnostic error. [Ref 1-8]

Note that applications which focus exclusively on the implementation of healthcare information technology, without a primary emphasis on diagnostic error in ambulatory care settings, are discouraged. 

Further guidance:

Priority Populations.  Diagnostic errors impact all populations regardless of age, gender, ethnicity, or socio-ethnic backgrounds.  However, these factors may underlie disparities of care received.  For example, a study that examined the rates of missed diagnosis of acute coronary syndrome in the emergency department found that patients who presented with acute cardiac ischemia were less likely to be hospitalized if they were women less than 55 years old, non-white, reported shortness of breath as their chief symptom, and had a non-diagnostic or normal electrocardiogram.  [Ref 9, 10] Priority populations continue to be an area of interest to AHRQ in this SEN.  For purposes of this SEN, priority populations include low-income patients and the uninsured along with AHRQ's other priority populations (children, women, elderly, racial and ethnic minorities, individuals with special health care needs).

Internal & External Validity/Replicability.  The Agency has a preference for supporting research designs that possess sound internal and external validity so that findings can be attributed to the interventions employed and can be generalized beyond a given organization or institution rather than apply solely to the applicant's particular setting.  Sufficient information needs to be given about any system or organizational context variables, which may have a bearing on dependent measures, that may limit the ability to draw generalizable inferences or that need to be known for purposes of replication or adoption.    

Use of Multiple Funding Mechanisms.  AHRQ will use standing grant mechanisms such as the R01, R03, R18, K08, and K02 funding mechanisms to support research on diagnostic errors.   

Limitations on Timelines and Funds.  Applications will be funded for 1 to 3 years.  Due to limitations on available grant funds, AHRQ limits the total (direct plus indirect) costs for the R01 and R18 mechanisms to no more than $300,000 per year.  R03 applications are limited to total (direct plus indirect) costs of no more than $100,000 per year. 

Application Submission.  With this notice, AHRQ is providing information about one of the highest research priorities for unsolicited applications for fiscal year 2008.  AHRQ will continue to provide regular updates of research priorities as research budget information becomes available.  Applications focused on areas identified in this SEN should be submitted on regular research grant receipt dates and will be reviewed by AHRQ’s standing study sections.  Information about the grant application process, including e-grant applications and the funding mechanisms noted above, can be found at http://www.ahrq.gov/fund/.


The AHRQ designated contacts for this SEN are:

R01, R03, and R18 inquiries:
            Kerm Henriksen, Ph.D.
            Center for Quality Improvement and Patient Safety
            Phone:  301-427-1331
            E-mail:  kerm.henriksen@ahrq.hhs.gov

K02 and K08 inquiries:
            Kay Anderson, Ph.D.
            Office of Extramural Research, Education, and Priority Populations
            Phone:  301-427-1555
            E-mail:  kay.anderson@ahrq.hhs.gov

Applicants are encouraged to contact the designated AHRQ staff early in the process of preparing applications in order to clarify questions and discuss potential research projects. 

  1. Graber, M   Diagnostic error in medicine: a case of neglect.  Joint Commission Journal on Quality and Patient Safety  2005: 31: 106-113.
  1. Graber, M, Gordon R, Franklin, N  Reducing cognitive error in medicine: what's the goal?  Academic Medicine  Oct. 2002: 77(10): 981-992.
  1. Croskerry, P  Diagnostic failure: a cognitive and affective approach. In Henriksen, K. Battles, JB., Marks, E., Lewin, DI. (Eds.)  Advances in Patient Safety:  From Research to Implementation.  Vol. 2, Concepts and methodology.  AHRQ Publication No. 05-0021-2. Rockville, MD: Agency for Healthcare Research and Quality; Feb 2005: 241-254.  
  1. Croskerry, P  Cognitive forcing strategies in clinical decision-making.  Annals of Internal Medicine  Jan. 2003:  41: 1.
  1. Croskerry, P  The importance of cognitive errors in diagnosis and strategies to prevent them.  Academic Medicine 2003: 78: 775-780. 
  1. Redelmeier, D. The cognitive psychology of missed diagnosis.  Annals of Internal Medicine 2005: 145: 115-120.
  1. Schiff, GD, et al.  Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. In Henriksen, K. Battles, JB., Marks, E., Lewin, DI. (Eds.)  Advances in Patient Safety:  From Research to Implementation.  Vol. 2, Concepts and methodology.  AHRQ Publication No. 05-0021-2. Rockville, MD: Agency for Healthcare Research and Quality; Feb 2005: 255-278.
  1. Groopman, J.  How Doctors Think.  New York: Houghton-Mifflin, 2007.
  1. Pope, J, et al. Missed diagnoses of acute cardiac ischemia in the emergency department.  The New England Journal of Medicine Apr. 2000: 342(16): 1163-1170.
  1. Mehta, RH, et al.  Missed diagnoses of acute coronary syndromes in the emergency room-continuing challenges.  The New England Journal of Medicine Apr. 2000: 342(16): 1207-1210.

Weekly TOC for this Announcement
NIH Funding Opportunities and Notices

Office of Extramural Research (OER) - Home Page Office of Extramural
Research (OER)
  National Institutes of Health (NIH) - Home Page National Institutes of Health (NIH)
9000 Rockville Pike
Bethesda, Maryland 20892
  Department of Health and Human Services (HHS) - Home Page Department of Health
and Human Services (HHS)
  USA.gov - Government Made Easy

Note: For help accessing PDF, RTF, MS Word, Excel, PowerPoint, Audio or Video files, see Help Downloading Files.