Concurrent Sessions

Tuesday, October 18

Oral Sessions 3 - Improving How We Diagnose: Paths to Diagnostic Excellence

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    Roni Matin

    Roni Matin, PhD, MSc

    Informatics Associate
    School of Biomedical Informatics, University of Texas Health Science
    Houston, TX

    Roni Matin is an Informatics Associate at the Center for Innovations in Quality, Effectiveness and Safety (iQuEST) at Baylor College of Medicine.  She is currently involved in AHRQ initiatives to develop diagnostic accuracy toolkits to improve diagnostic accuracy for cancer via telemedicine and a center for patient safety at iQuEST. Roni completed her PhD in Biomedical Informatics with a focus on human factors and clinical decision making, from the McWilliams School of Biomedical Informatics at the University of Texas Health Science in Houston.  In addition to her research experience, she has extensive experience in implementation from her previous systems analyst and project manager roles, during which she has implemented a variety of healthcare and business systems, both in the UK and overseas.



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    Joseph Tholany, MD

    University of Iowa
    Iowa City, IA
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    David Newman-Toker

    David Newman-Toker, MD, PhD

    Professor of Neurology
    Johns Hopkins University School of Medicine
    Baltimore, MD

    David E. Newman-Toker, MD PhD is an internationally-recognized leader in neuro-otology, acute stroke diagnosis, and the study of diagnostic errors. He completed his undergraduate studies at Yale University, his medical degree at University of Pennsylvania, his residency and neuro-ophthalmology fellowship training at Harvard University, his neuro-otology fellowship training at Johns Hopkins University School of Medicine, and his doctoral degree in clinical research methods at the Johns Hopkins Bloomberg School of Public Health. He has served as a full-time faculty member at the Johns Hopkins University School of Medicine since 2002. He is Professor of Neurology, Otolaryngology, and Ophthalmology, with joint appointments in Emergency Medicine, Acute Care Nursing, Health Sciences Informatics, Epidemiology, and Health Policy & Management at Johns Hopkins. Dr. Newman-Toker’s clinical and research focus is in diagnosis of acute disorders affecting the brainstem and cranial nerves, particularly stroke. He is recognized for his research in novel eye-movement-based bedside methods for diagnosing stroke in patients with acute dizziness and vertigo in the emergency department. He serves as Director of the Division of Neuro-Visual & Vestibular Disorders in the Department of Neurology. He also directs the Armstrong Institute Center for Diagnostic Excellence whose mission is to catalyze efforts to improve diagnostic performance, develop the science of diagnostic safety, and enhance diagnostic research. He has been the principal investigator for multiple NIH, AHRQ, and foundation grants. He has published over 135 journal articles and given more than 250 invited lectures on dizziness and diagnostic errors. He is a leader in the national and international movements to eliminate patient harms from diagnostic error. He has served as an expert consultant on diagnostic safety and quality to AHRQ, the National Quality Forum, and the National Academy of Medicine. He served as President of the Society to Improve Diagnosis in Medicine (SIDM) from 2018-2020.

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    Laurel Officer, MD

    Resident Physician
    Brooke Army Medical Center
    San Antonio, TX

    Laurel Officer, MD is a third-year neurology resident at San Antonio Uniformed Services Health Education Consortium (SAUSHEC), one of the DoD Graduate Medical Education programs. She graduated from University of Colorado School of Medicine in 2020. Her focus has centered on quality improvement initiatives to promote patient safety.

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    Mark Graber, MD, FACP

    Mark Graber, MD, FACP

    Society to Improve Diagnosis in Medicine

    Dr. Graber is Professor Emeritus at Stony Brook University. He has an extensive background in biomedical and health services research, with over 150 peer-reviewed publications. He originated Patient Safety Awareness Week in 2002, an event now recognized internationally. He is the 2014 recipient of the John M Eisenberg Award for Patient Safety and Quality, awarded by The Joint Commission and the National Quality Forum, the nation's top honor in the field of patient safety.    Dr. Graber has been a pioneer in efforts to address diagnostic errors in medicine, and his academic work in this area has been supported by the National Patient Safety Foundation, the Agency for Healthcare Research and Quality, and the Office of the National Coordinator for Health Information Technology. He convened and chaired the first Diagnostic Error in Medicine conference in 2008, and in 2011 he founded the Society to Improve Diagnosis in Medicine (SIDM), and served as President from 2011 through 2018.


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    Jean-Luc Tilly

    Jean-Luc Tilly

    Program Manager in Health Care Ratings
    The Leapfrog Group
    Washington, DC

    Jean-Luc Tilly joined The Leapfrog Group in 2020 and works directly with experts and stakeholders to identify new opportunities for measurement and coordinates activities of Leapfrog’s public reporting and rating programs. At Leapfrog, Jean-Luc co-leads the Recognizing Excellence in Diagnosis program funded by the Gordon and Betty Moore Foundation. The program recommends practices hospitals can adopt to improve diagnostic quality and safety, eventually leading to a publicly reporting dataset on hospital performance in diagnostic safety and quality to engage consumers and purchasers and foster meaningful accountability for hospitals. Jean-Luc currently co-leads the Patient Expert Panel, identifying new measurement opportunities in hospital billing practices and the informed consent process. He also provides technical assistance to hospitals and health systems around the country working to implement Leapfrog’s standards. Before joining Leapfrog, Jean-Luc served for over four years as a Senior Project Manager at the National Quality Forum, focusing on NQF’s project to improve diagnostic safety and quality, NQF’s Measure Applications Partnership with CMS to add new measures to federal reporting programs, and NQF’s Measure Selection Tool (MSeT). Earlier, Jean-Luc worked on the 2014 edition of AARP’s Long-Term Services and Supports Scorecard, and with the Center to Champion Nursing in America. He earned his Master’s in Public Administration from George Washington University in 2019.


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    Rick Roos, MD

    Rick Roos, MD

    Haga Teaching Hospital

    An Internal Medicine resident researching the diagnostic process on the emergency department using the Safety-II approach.


Authors will present peer-reviewed abstracts of the latest innovations in diagnostic safety research, practice improvement, and education, and will answers questions from the audience.

Learning Objectives

  • Describe new and innovative research related to diagnostic safety;
  • Discuss innovative practice improvement strategies for improving diagnosis in medicine;
  • Identify high-quality medical education methodologies to improve clinical reasoning and reduce diagnostic error.

Oral Abstract Titles and Presenting Authors

  • Identifying Risk Factors for Diagnostic Error Involving Emergency Medicine Transitions of Care – Roni Matin, Informatics Associate, School of Biomedical Informatics University of Texas Health Science
  • Frequency and Duration of Diagnostic Delays for Q Fever – Joseph Tholany, Physician, University of Iowa
  • Remote Expert Diagnosis is More Accurate than In-Person ED Diagnosis in Acute Vertigo (AVERT Trial) – David Newman-Toker, Professor of Neurology, Johns Hopkins University School of Medicine
  • Heads Will Roll: Overutilization of MRI in Diagnosis of Posterior Circulation Stroke – Laurel Officer, Resident Physician, Brooke Army Medical Center
  • Recognizing Excellence in Diagnosis - Leapfrog's New Project REDx – Mark L. Graber, Founder and President Emeritus, Society to Improve Diagnosis in Medicine; Jean-Luc Tilly, Program Manager in Health Care Ratings, The Leapfrog Group
  • Learning from Correct Diagnoses: A Safety-II Approach – Rick Roos, Researcher, Haga Teaching Hospital

Safeguarding the Future of Diagnosis-Advancing Organizational Excellence with the Safer Dx Checklist

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    Patricia McGaffigan, RN, MS, CPPS

    Patricia McGaffigan, RN, MS, CPPS

    Vice President, Safety; President, Certification
    Board for Professionals in Patient Safety
    Institute for Healthcare Improvement
    Boston, MA

    Patricia is President, Certification Board for Professionals in Patient Safety, and Vice President at the Institute for Healthcare Improvement where she is IHI’s senior sponsor for the National Steering Committee for Patient Safety. She is the former Chief Operating Officer and Senior Vice President of Safety Programs at the National Patient Safety Foundation. Patricia is a Certified Professional in Patient Safety (CPPS), a graduate of the AHA-NPSF Patient Safety Leadership Fellowship Program and is a member of the Joint Commission National Patient Safety Committee, the Joint Commission Journal on Quality and Patient Safety Editorial Advisory Board, and the Advisory Committee of the Coalition to Improve Diagnosis. Patricia serves as a Board Member of the Massachusetts Coalition for the Prevention of Medical Errors and on Planetree’s Person-Centered Certification Committee. Patricia represents IHI on numerous committees, taskforces and professional panels and is a frequent speaker at national and regional conferences. A recipient of the Lifetime Member Award from the American Association of Critical Care Nurses, Patricia received her BS in Nursing from Boston College and her MS in Nursing from Boston University.

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    Hardeep Singh, MD, MPH

    Chief, Health Policy, Quality & Informatics Program
    Michael E. DeBakey VA Medical Center
    Houston, TX

    Hardeep Singh, MD, MPH, Co-Chief, Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston  Hardeep Singh, MD MPH is a Professor of Medicine at the Center for Innovations in Quality, Effectiveness and Safety (IQuESt) based at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston. He leads a portfolio of multidisciplinary patient safety research related to measurement and reduction of diagnostic errors in health care and improving the use health information technology. His research has informed several national and international patient safety initiatives and policy reports, including those by the National Academies, CDC, NQF, AMA, ACP, AHRQ, OECD and the WHO. He serves as a nominated member of National Academies' Board of Health Care Services and is an elected Fellow of the American College of Medical Informatics for significant and sustained contributions to the field of biomedical informatics. His contributions include co-developing the "ONC SAFER Guides" which are CMS required guides that provide national recommendations for safe electronic health record use, co-chairing or participating on several national panels and workgroups on measuring or improving safety, and developing pragmatic resources to promote patient safety and diagnostic excellence in clinical practice. He has received several prestigious awards for his pioneering work, including the AcademyHealth Alice S. Hersh New Investigator Award in 2012, the Presidential Early Career Award for Scientists and Engineers (PECASE) from President Obama in 2014, the VA Health System Impact Award in 2016 and the 2021 John M. Eisenberg Patient Safety and Quality Award for Individual Lifetime Achievement.

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    Trish Anderson

    Trish Anderson, MBA, BSN, CPHQ

    Senior Director of Safety & Quality
    Washington State Hospital Association
    Seattle, WA

    Trish Anderson is a Senior Director of Safety & Quality at the Washington State Hospital Association where she leads strategic initiatives on Diagnostic Excellence.

1.50 CME/CNE

Most health care organizations find diagnostic safety hard to address. While much attention has focused on individual clinician practices, resources that provide practical, organization-wide guidance have been lacking. This workshop highlights the “Safer Dx Checklist”, a novel tool to help organizations implement a systems approach to improving diagnosis. The Checklist was developed using a rigorous multimodal approach including a modified Delphi process and an advisory panel that included interprofessional experts and patients. The Checklist includes 10 high-priority safety practices for advancing diagnostic excellence in organizations. It provides a framework to conduct a self-assessment to understand the current state of diagnostic practices, identify areas to improve, and track progress over time. This interactive session will describe the 10 practices and provide pragmatic guidance to aid their implementation, including examples and lessons learned from users. Attendees will assess their organization’s current state and create a plan for their organization to advance progress on their diagnostic excellence journey. Session faculty includes physicians, a nurse, and a patient partner who were integrally involved in developing the Checklist.

Learning Objectives

  • Identify high priority foundational practices for health care organizations to improve diagnosis & reduce diagnostic error;
  • Implement an organizational assessment checklist to identify opportunities to advance diagnostic excellence;
  • Develop a plan for your organization to improve diagnosis.


Stigmatizing Language and the Diagnostic Process: Recognizing and Addressing Implicit Bias

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    Katie Raffel, MD

    Katie Raffel, MD

    Assistant Clinical Professor, Hospital Medicine
    University of Colorado
    Denver, CO

    Dr. Raffel recognizes the importance of the system of care in achieving excellent diagnostic outcomes and has dedicated her early career to understanding inpatient diagnostic error and systems prevention. Dr. Raffel is a part of the UPSIDE (Using Predictive Systems to identify Inpatient Diagnostic Error) study, an ongoing AHRQ-funded multi-site study evaluating diagnostic error among ICU escalations or inpatient death. She also currently serves as core faculty at the Institute for Healthcare Quality Safety and Efficiency, an organization dedicated to transforming people, processes in order to improve organizations and patient outcomes.

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    Farah Kaiksow, MD

    Farah Kaiksow, MD

    Assistant Professor of Hospital Medicine
    University of Wisconsin School of Medicine and Public Health
    Madison, WI

    Dr. Farah Kaiksow is an Assistant Professor of Hospital Medicine in the Department of Medicine at the University of Wisconsin School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital, where she works with residents and medical students. She was previously the Medical Director of Quality for the Division of Hospital Medicine. She sits on the Department of Medicine's Diversity, Equity, and Inclusion Committee, and as core faculty for both Internal Medicine residency pathways in Health Equity and Global Health. Her research is centered around health disparities. Prior work examined Medicare and Medicare Advantage hospitalization policies and their impact on people of different socioeconomic status. Her current research focuses on health care for people who are or have been incarcerated. Specifically, she is studying the impact of hospitalizations and restraint use on older incarcerated adults.

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    David Chia, MD

    David Chia, MD

    Associate Professor of Clinical Medicine
    San Francisco General Hospital
    San Francisco, CA

    Dr. David Chia is an Associate Professor of Clinical Medicine at UCSF. He graduated from the University of Minnesota Medical School and completed his residency training at the Yale Primary Care Internal Medicine Residency Program. Dr. Chia is currently an academic hospitalist at Zuckerberg San Francisco General Hospital, where he is Site Director for the Residency, Director of Clinical Operations and Director of Clinical Innovations. His academic interests include quality improvement, curriculum development, point-of-care ultrasound, and global health.

1.50 CME/CNE

Stigmatizing language is common in the electronic health record. This language may question patient credibility, portray racial or class stereotypes, communicate disapproval or emphasize patient temperament or behaviors and is often reflective of implicit bias. Implicit bias is known to impact patient-provider communication, shared decision-making, and trust, and contributes to a range of poor health outcomes.  Stigmatizing language in the medical record may also contribute to diagnostic errors. Preliminary work from the Using Predictive Systems to Identify Inpatient Diagnostic Errors (UPSIDE) Study evaluating diagnostic errors among hospitalized patients demonstrated that stigmatizing language was higher among patients who experienced diagnostic errors than those without diagnostic errors. The presence of stigmatizing language was also associated with multiple diagnostic process breakdowns.  Clinicians should be able to recognize stigmatizing language and its potential effects on clinical care. Providers should also be able to address the use of such language with trainees and peers, even in uncomfortable situations. This workshop will provide participants with the skills needed to avoid stigmatizing language in their own practice and to counsel others on mitigating it.

Learning Objectives

  • Define stigmatizing language in the medical record;
  • Identify the impact of stigmatizing language on diagnostic processes and outcomes;
  • Develop an approach to addressing stigmatizing language with trainees and peers.


SIDM Fellow Presentations

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    Carl Berdahl, MD, MS, FACEP

    Assistant Professor in Emergency Medicine
    Cedars-Sinai Medical Center
    Los Angeles, CA

    Dr. Berdahl is an emergency physician and health services researcher with appointments as Assistant Professor at Cedars-Sinai, Assistant Professor at UCLA, and Physician Policy Researcher at RAND. His research interests are broad, but he generally focuses on detecting and preventing diagnostic errors and improving other aspects of quality and safety in the acute care setting. Current funded work related to diagnostic error includes: (1) a SIDM DxQI grant to develop a systematic feedback loop between the Cedars-Sinai intensive care unit and the emergency department to alert ED clinicians about clinically significant diagnostic errors; and (2) a Moore Foundation grant to develop a patient experience measure characterizing the timeliness of cancer diagnosis. In the future, Dr. Berdahl hopes to obtain federal funding to study patient-reported diagnostic errors among patients who were treated and released from the emergency department.

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    Leah Burt, PhD, APRN

    Clinical Assistant Professor
    University of Illinois Chicago
    Chicago, IL

    Dr. Leah Burt is a board certified Adult Primary Care Nurse Practitioner. She maintains an active clinical practice within the University of Illinois Hospital and Health Sciences System's Department of Emergency Medicine and is a Clinical Assistant Professor as well as the Director of the AGPC-NP Program at the University of Illinois Chicago. Dr. Burt's area of research expertise is mixed methodology educational research. Specifically, she is interested in evidenced-based strategies to teach diagnostic reasoning, as well as experiential and simulation-based learning interventions. A former Fellow in Diagnostic Excellence with the Society to Improve Diagnosis in Medicine (SIDM), she is currently a Simulation Scholar at University of Illinois College of Medicine's Simulation and Integrative Learning (SAIL) Institute. Dr. Burt has published and presented her scholarship both nationally and internationally and is passionate about finding innovative, experiential ways to further diagnostic reasoning education.

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    Da Jin, MD

    Fellow in Medical Informatics and Clinical Epidemiology
    Oregon Health and Science University
    Portland, OR
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    Casey McQuade, MD

    Clinical Assistant Professor of Medicine
    University of Pittsburgh Medical Center
    Pittsburgh, PA

    Casey McQuade, MD is an academic hospitalist at the University of Pittsburgh Medical Center, where he also completed his residency in internal medicine as well as a chief resident year. He is the current Director of Graduate Education for the UPMC Clinical Center for Medical Decision Making. He is also director of the Certificate Program in Clinical Reasoning for the UPMC Internal Medicine Residency Program. Casey is currently working towards his Masters of Medical Education through the University of Pittsburgh. His main academic interests include diagnostic reasoning education at the GME and UME levels, and the utility of social media for medical education. His current research focuses on the development of expertise in diagnostic reasoning with particular emphasis on differences in how novices and experts develop problem representations for clinical problems. He was awarded one a Fellowship in Diagnostic Excellence by SIDM and the Gordon and Betty Moore Foundation in 2021.

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    Edwin Rosas

    Edwin Rosas

    Academic Hospitalist
    UChicago Medicine
    Chicago, IL
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    Sarah Slone

    PhD Student
    Johns Hopkins University
    Baltimore, MD

    Sarah Slone is a PhD student at Johns Hopkins University School of Nursing and an assistant professor of nursing at University of South Carolina. She has expertise in cardiovascular and implementation research. Her current research examines patient and provider factors that influence diagnostic testing referral patterns for patients presenting with acute chest pain. She has worked on studies focused on assessing quality of life in school-aged children with asthma, impact of same day discharge on patients status post percutaneous coronary intervention, and various device studies. She earned her BSN from the University of South Carolina, her MSN-FNP from Georgetown University, and her DNP from Johns Hopkins University. She is a member of Sigma Theta Tau Honor Society Alpha Xi chapter. Currently, she serves on the ACC CV Team Education Committee and is president of the PhD Students Organization. Sarah was one of the first undergraduate nursing students to receive the Magellan Scholar Program Grant Award through the UofSC Office of Research. In 2021, she was selected as a fellow in diagnostic excellence by the Society to Improve Diagnosis in Medicine and received funding from the Gordon and Betty Moore Foundation.

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    Kelsey Ufholz, PhD

    Research Scientist
    Case Western Reserve University Department of Family Medicine and Community Health
    Cleveland, OH

    I am a behavioral scientist with a strong background in health behavior and research methodology where I design and implement interventions to improve the quality of primary care. Much of my work focuses on diagnosis and management of chronic illnesses, such as obesity, diabetes, cancer, and hypertension. I spent almost 4 years as a postdoctoral researcher for the United States Department of Agriculture. During that time, I was a Co-Principal Investigator on 6 research projects in the Healthy Body Weight Research Unit, all related to exercise behavior both in adults and children ages 8-12, diet behavior, and/or sedentary behavior. I am currently a research scientist at Case Western Reserve University’s Department of Family Medicine and Community Health, under the mentorship of Dr. Goutham Rao, a leading expert for both adults and children on conditions including hypertension, diabetes, and obesity. Many of my recent projects explore the use of novel technology for patients across the lifespan. These include virtual peer support groups for diabetes management, active video games to increase active play in children, and a survey to examine older primary care patients experience with and barriers to using telemedicine. I am the recipient of a pilot award to implement and evaluate peer support groups for patients with diabetes and obesity. I also received a highly competitive 2021-2022 fellowship from the Society to Improve Diagnosis in Medicine to examine recognition rates and diagnostic pathways associated with unintentional weight loss, a common, yet frequently underdiagnosed marker of cancer.


This interactive and entertaining session will focus on important updates and controversies in diagnosis and diagnostic error from the last year, including education, theory, practice, and patient engagement. The audience will engage with presenters in discussing the highlights from the literature.
Learning Objectives

  • Describe emerging research, quality improvement projects, and educational initiatives focused on improving diagnostic safety;
  • Identify novel areas of inquiry in the science of diagnosis;
  • Discuss challenges in conducting longitudinal projects around diagnostic safety.