NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Understanding What Happened

1. What happened? Begin by understanding the sequence of events leading up to the sentinel event. Gather detailed information about the incident, including the timeline, people involved, and context. 
   • Who did the problem/event affect, and how?

In a busy Emergency Department (ED), a recent incident showed how Diagnostic Errors (DEs) can put patient safety and care at risk. A 41-year-old female arrived at the ED with conditions of chest pain, shortness of breath, and a mild cough. During a busy shift, her symptoms were diagnosed as pneumonia, and she was started on antibiotics without a thorough investigation. Because of this diagnostic error, a Computed Tomography (CT) pulmonary angiogram and appropriate blood tests were not ordered. A few hours later, her condition worsened, and she suddenly collapsed, prompting urgent imaging that revealed a severe pulmonary embolism. She was immediately started on anticoagulation therapy and transferred to the intensive care unit for close monitoring. While the staff focused on stabilizing her, care for other patients was delayed.

This increases the strain in the ED. The late diagnosis resulted in a longer hospital stay, the need for rehabilitation, and higher medical costs. This case shows that mistakes at any point in the diagnostic pathway, such as initial evaluation, handoff communication, and follow-up, can harm patients, burden staff, and lower efficiency. It emphasizes the need for standardized diagnostic procedures, reliable communication outlines like SBAR (Situation, Background, Assessment, Recommendation), and supportive technology such as Clinical Decision Support Systems (CDSS). In the United States (U.S), a projected one million people each year suffer damage to their skills due to DEs, with the severity of impairment being modest to severe in up to 86% of situations (Porter et al., 2021). These errors increase healthcare expenses, making prevention strategies critical.

1. Why did it happen?
   • Human Factors: Investigate whether communication breakdowns, staff fatigue, or lack of training contributed.
   • System Factors: Examine workflow processes, equipment failures, and environmental factors.
   • Organizational Culture: Assess if there are cultural issues, a lack of safety culture, or inadequate leadership support.
   • Society/Culture: What role might cultural assumptions or backgrounds play?

Human Factors: Several human factors contribute to DEs in hospitals. One of the major issues is staff shortages. This requires staff to work long hours, dealing with fatigue and stress. This makes it harder for physicians and nurses to stay focused and can affect the accuracy of clinical decisions due to constant time pressure and workloads. Limited training in areas like diagnostic reasoning, test interpretation, and health technology use makes it challenging to avoid mistakes.

Another important issue is poor communication and follow-up. When important information is lost during handoffs and patient transfers, it leads to delays in treatment and harm to the patient (Hooftman et al., 2024). Administrative burdens on providers reduce time for thorough diagnostic work. It increases the hazard of DEs and compromises patient security and healthcare standards.

NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

System Factors: Influence the pace and development of diagnostic mistakes in healthcare environments. A key issue is the lack of standard diagnostic procedures and verification mechanisms. In high-pressure zones like the ED, poorly defined processes for evaluating, ordering examinations, and interpreting results lead to delayed and incorrect diagnoses. Research indicates that test results are not always clearly communicated, monitored, or addressed. Occasionally, abnormal findings are overlooked due to Electronic Health Record (EHR) challenges (Hooftman et al., 2024).

This is attributed to the absence of standardized discharge follow-up procedures. In addition, poor decision-support technology utilization elevates the likelihood of missed detection. Such inefficiencies raise levels of provider stress and compromise patient safety (Hooftman et al., 2024). Creating an integrated system that incorporates CDSS, evidence-informed diagnostic checklists, and structured communication tools such as SBAR is crucial to error minimization and assured consistent clinical practice.

Organizational Culture: Ineffective organizational culture is a key determinant of diagnostic error occurrence in hospitals. Without a strong emphasis on teamwork and interprofessional collaboration, and without planned standards of evaluation and follow-up, the environment is made unsafe for proper diagnosis. In high-demand environments like the ED, early clinical warning signs and partial assessments are often overlooked as mere challenges (Hansen et al., 2023).

This leads to the staff not receiving adequate support, allowing systemic weaknesses to occur. Proper team functioning, collective responsibility, and institution-wide diagnostic systems are key to avoiding such risks. A positive workplace culture encourages constant learning, open reporting of errors without reprisals, and open communication (Hansen et al., 2023). Such a culture is instrumental in guaranteeing a healthcare system that safeguards patients and caregivers.

NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Society/Culture: Social and cultural dynamics are crucial in the incidence of errors in clinical care. Variations in cultural beliefs, language barriers, and communication approaches between staff and patients can lead to misinterpretation of symptoms, incomplete medical histories, and poor understanding of follow-up instructions. Limited cultural skills and ineffective communication increase the risk of missed and delayed diagnoses, which can threaten patient safety (Auerbach et al., 2024).

Creating a care setting that provides professional interpretation services, explains diagnostic findings in simple and accessible terms, and trains staff in culturally sensitive communication helps reduce miscommunication. This improves patient understanding, enhances diagnostic accuracy, and supports safer clinical decision-making.

1. Was there a deviation from protocols or standards?
   • Procedures and Policies: Determine if established protocols were followed or if there were deviations.
   • Were there any steps that were not taken or did not happen as intended?
   • Documentation: Review medical records, nursing notes, and other relevant documentation.

In hospital settings where diagnostic safety is weakened, compliance with evaluation protocols and thorough documentation declines. Within an ED, a recent case showed how a single missed diagnosis can turn into a major threat to patient outcomes. A female arrived at the ED with respiratory problems. During a busy shift, her symptoms were labeled as pneumonia, and antibiotics were started without further investigation. Because of this error, critical tests such as a CT pulmonary angiogram and blood work were not ordered. A few hours later, her condition suddenly worsened, and urgent imaging revealed a severe pulmonary embolism.

She required anticoagulation therapy and was admitted to the intensive care unit for close observation. While the team concentrated on stabilizing her, care for other patients was delayed, adding pressure on the ED. Failure to follow proper diagnostic verification steps broke institutional standards and disrupted coordinated care. Clear, structured policies, effective communication, and real-time documentation during handovers are essential to prevent such oversights (Risani et al., 2024). In this case, a communication gap, the lack of standardized reporting systems, and decision-support tools allowed key information to be missed. This raises the hazard of repeated mistakes and compromises defense.

1. Who was involved?
   • Staff: Identify the roles of individuals directly involved in the event.
   • Supervisors and Managers: Investigate

NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

The prevention of screening mistakes and the delivery of safe, consistent care rely on the shared efforts of clinicians, nurses, and healthcare leadership. In a recent ED case, a 41-year-old female presented with difficulty breathing and pain. During a busy shift, her symptoms were misdiagnosed as pneumonia, and antibiotics were started without further testing. The exact cause of a severe pulmonary embolism was only discovered hours later, after her condition suddenly worsened, requiring urgent imaging, anticoagulation therapy, and ICU admission.

This event exemplifies the importance of collective responsibility. Attending staff must carry out comprehensive evaluations, document thoroughly, and exchange accurate information during handoffs. Leadership, including charge nurses and department managers, must prioritize diagnostic safety by ensuring protocols are followed and communication systems are strong. Weak oversight, lack of supervision, and failure to enforce safety standards continue to drive preventable diagnostic mistakes. Constant training, active monitoring, and standardized communication outlines like SBAR during care transitions are critical to detecting risks early and avoiding diagnostic-related harm (Risani et al., 2024).

1. Was there a breakdown in communication?
   • Interdisciplinary Communication: Assess how well different teams communicated.
   • Patient-Provider Communication: Explore whether patients were informed and understood their care.

In a recent ED event, communication breakdowns introduced unsafe environments that compromised diagnostic quality and care coordination. While working a busy evening shift, physicians were preoccupied with numerous high-priority cases, which disrupted the effective sharing of patient information at handoff. Crucial details regarding a 41-year-old woman’s respiratory problems and recent symptom evolution were not adequately shared. This knowledge gap facilitated her illness being misdiagnosed as pneumonia, with a delay in the identification of a large pulmonary embolism.

Jawad et al. (2024) highlight that enhancing diagnostic safety needs uniform usage of clinical practices, clarified communication, and precise documentation. Poorly organized handover procedures and follow-up systems permitted important steps to be missed. Restricted patient engagement eliminated constant symptom expression, thus delaying escalation of care. This incident illustrates how breakdowns in communication and protocol following can undermine diagnostic safety, interrupt timely intervention, and increase the likelihood of severe complications.

1. 1. What were the contributing factors?
      • Physical Environment: Consider facility layout, equipment availability, and workspaces.
      • Staffing Levels: Evaluate if staffing was adequate.

• Training and Competency: Assess staff’s knowledge and skills.

Physical Environment: The physical layout of hospitals influences diagnostic safety and opportunities for errors. In crowded EDs, poorly designed spaces lead to confusion that makes communication more difficult for staff and performing accurate evaluations more challenging. For instance, in one situation, the absence of quiet areas for assessment and high background noise levels made it challenging for clinicians to assess a 41-year-old woman with difficulty in breathing and chest pain thoroughly. This led to critical information being overlooked, and her illness was wrongly diagnosed as pneumonia rather than a pulmonary embolism.

Additionally, small monitoring spaces and inaccessible workstation locations hindered the effective use of EHR and CDSS, which could have facilitated more accurate diagnoses. These physical issues, compounded by heavy patient loads and frequent interruptions, compromised documentation quality and prolonged clinical decision-making. Pattaro et al. (2025) clarify that poorly designed facilities that impede communication and disrupt diagnostic processes increase the risk of missed and delayed diagnoses. This can delay treatment and allow harm to occur before the error is recognized.

Staffing Level: Inadequate staffing continues to be a major contributor to DEs in healthcare settings. Persistent workforce shortages compel clinicians to work extended hours. This results in fatigue and cognitive overload. Exhausted staff, without sufficient support, are less able to follow critical diagnostic safeguards such as comprehensive history-taking, timely ordering of imaging studies, structured use of differential diagnosis frameworks, and adherence to standardized protocols (Jawad et al., 2024). While CDSS embedded in EHRs can assist by automatically integrating these evidence-based tools into workflows, fatigued staff are less likely to engage efficiently with these systems.

NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

The mental and physical strain of managing multiple urgent cases reduces attention to detail, increasing the risk of incomplete documentation, missed differential diagnoses, and poor communication during shift handovers. In high-acuity environments such as the ED, overextended staff overlook CDSS alerts and delay critical diagnostic tests. Chronic understaffing restricts timely consultations with specialists and collaborative decision-making. These are essential for diagnostic accuracy (Hooftman et al., 2024). Ensuring optimal clinician-to-patient ratios with active use of EHR-integrated CDSS is vital for reducing DEs and safeguarding patient outcomes.

Training and Competency: Nurses and physicians are well-trained in providing direct patient care. Inadequate training in diagnostic safety practices increases the chances of errors that can adversely impact outcomes. When clinicians are not consistently trained in using structured approaches such as SBAR communication, diagnostic checklists, and EHR-integrated CDSS, important steps in the diagnostic process are overlooked.

Inadequate education contributes to gaps in documentation, incomplete assessments, and misinterpretation of test findings. Constant competency-based training helps build confidence, sharpen clinical judgment, and encourage reliance on standardized protocols. It supports teamwork across disciplines and improves awareness when managing patients with complex conditions (Jawad et al., 2024). Healthcare staff must undergo regular education on diagnostic safety to reduce communication errors and minimize the incidence of diagnostic mistakes.

1. Did organizational policies or procedures play a role?
   • Policy Compliance: Investigate if policies were followed.
   • Policy Clarity: Assess if policies are clear and accessible.

NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

The case was shaped by failures in following established diagnostic safety practices that are designed to reduce errors and support timely care. Although resources such as structured handoff communication, SBAR, EHR, CDSS, and standardized diagnostic protocols are available, they were not applied consistently because of unclear guidance, limited accessibility, and a lack of constant support. Important abnormal findings were unnoticed, and necessary follow-up tests were delayed. Uncertainty around documentation requirements slowed down the recognition and correction of mistakes (Risani et al., 2024). Additionally, outdated diagnostic policy guidelines led to inconsistent clinical decisions and created barriers to effective communication. These shortcomings increased the chance of preventable DEs and delayed treatment.

1. Was there a failure in monitoring or surveillance?
   • Vital Signs Monitoring: Check if there were any missed signs.
   • Alarm Fatigue: Explore if alarms were ignored.

When diagnostic safety protocols are not followed consistently, patient assessments can suffer in busy healthcare settings. Clinicians dealing with high workloads, constant interruptions, and mental fatigue fail to recognize warning signs and abnormal test results. For example, in a recent case, unclear communication during shift changes and distractions in the ED led to important symptoms and vital sign changes being overlooked.

Overreliance on electronic alerts from poorly optimized EHRs and CDSS sometimes failed, as staff became desensitized to repeated notifications. In high-acuity areas, this combination of stress and alert fatigue can delay critical decisions, like ordering timely imaging and lab tests. This increases the risk of misdiagnosis (Hooftman et al., 2024). This highlights the need for clear diagnostic protocols, regular staff training, and better use of technology to ensure alerts support, rather than overwhelm, clinicians in making safe and accurate decisions.

1. What can be learned to prevent recurrence?
   • Lessons Learned: Identify systemic changes, training needs, and improvement opportunities.
   • Quality Improvement: Consider implementing preventive measures.

NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Decreasing diagnostic error in healthcare depends upon organization-wide strategies that emphasize prevention, open communication, and mutual accountability among health teams. One key strategy is educating personnel to identify early warning signals of possible misdiagnoses and act on them based on evidence-based diagnostic practices (Jawad et al., 2024). Continuous professional education emphasizes thorough patient evaluation, cautious interpretation of laboratory and imaging findings, and verification of abnormal results. Utilizing planned communication techniques like SBAR enhances the precision of data exchange between physicians and minimizes misinterpretations that can result in delayed diagnoses.

Training of staff aids a culture of safety by increasing attentiveness and promoting collaboration among disciplines (Risani et al., 2024). Healthcare facilities should utilize sophisticated EHRs and CDSS, enhance alert conditions to minimize fatigue, and apply patient-flagging regulations to identify critical cases. Systematic reviews of diagnostic strategies provide for regular follow-up and accountability. Clearly formulated checklists ensure confirmation that important information, such as patient history, test results, and changes in symptoms, is reviewed at each point. These strategies minimize DEs and enhance security results in patients (Pattaro et al., 2025).

1. 1. How can patient safety be enhanced?
      • Risk Mitigation: Develop strategies to minimize risks.
      • Education and Training: Ensure staff are well-trained.

• Reporting and Feedback: Encourage open reporting and learning from mistakes.

Regular training in diagnostic practices assists staff in recognizing early warning signs and responding quickly. This reduces the risk of misdiagnoses and improves clinical judgment (Pattaro et al., 2025). Learning through real-life scenarios builds problem-solving, compliance, and arrangement skills in high-pressure ED care settings. Establishing physical and digital workspaces, such as distinct evaluation areas, user-friendly EHR dashboards, integrated CDSS alerts, and organized documentation stations, makes it simpler to evaluate information accurately and avoid missed findings.

Studies show that healthcare facilities with robust diagnostic safety systems experience fewer errors and better patient outcomes (Hughes, 2021). Regular safety checks, a supportive setting for reporting DEs, and constructive feedback help nurses learn from near-misses while detecting frequent challenges. Engaging patients and their families in conversations about symptoms, test results, and care plans improves understanding, encourages informed decisions, and reduces the chances of delayed and incorrect diagnoses.

Root Cause – the most basic reason that the situation occurred

Contributing Factors – additional reason(s) that clearly made a situation turn out less than ideal

HFC

HF T

HF

F/S

E

R

B

Communication Gap

Workload and Time Constraint

Lack of Staff Training and Safety Measures

1

DEs contribute to communication failures among staff, resulting in incomplete sharing of detailed patient data, delays in testing and treatment, and increased risks to patient safety.

HFC

2

Inadequate staffing and high patient volumes require clinicians to work long hours while managing multiple diagnostic tasks under pressure. This causes mental exhaustion and cognitive overload, reducing focus and clinical reasoning. Important patient symptoms, test results, and diagnostic findings were missed and communicated inaccurately, increasing the risk of DEs.

HFF

3

Interruptions in communication procedures weaken the safe and accurate completion of diagnostic tasks, reducing staff focus and adherence to procedures. Insufficient training in diagnostic safety and unclear guidance on evaluation and follow-up procedures can lead to misinterpreted patient data, increasing the chance of DEs.

R

DEs create insecure conditions and contribute to preventable adverse outcomes. This poses a serious threat to patient safety. Failures in communication during patient assessment, test ordering, and result interpretation compromise clinical accuracy and increase the chance of harm. In high-acuity settings such as the ED, the difficulty and fast pace of care intensify these risks. Around 5.7% of ED visits involve a diagnostic error. This translates to over 7 million errors yearly in the United States (U.S.). However, 2.6 million cause harm and nearly 371,000 lead to serious outcomes (Toker et al., 2022). DEs are linked with morbidity and mortality, impacting patients across all age groups. The financial burden is substantial, as misdiagnoses lead to redundant tests, extended hospital stays, and extra treatments, costing the U.S. healthcare system billions annually. The cost of diagnostic mistakes is projected at USD 19.5 billion annually, with a financial influence advancing USD 1 trillion per year (Porter et al., 2021).

NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Addressing these threats requires evidence-based strategies, including professional growth and regular training that enhance staff’s diagnostic reasoning, follow-up, and communication skills. Organization-wide interventions, such as standardized diagnostic protocols, integrated CDSS, and optimized EHR, enhance accuracy, improve patient safety, and reduce both clinical and financial risks (Hughes, 2021). Repetitive safety audits, a culture of transparent error reporting, and feedback rounds help identify persistent susceptibilities and support improvement. Actively engaging patients and their families in discussions about symptoms, test results, and care plans promotes informed participation, better adherence, and a culture of diagnostic safety across healthcare settings (Hughes, 2021).

Healthcare administrations must implement applied approaches that prioritize clinician expertise and patient safety to reduce DEs. A crucial approach involves early recognition of high-risk situations through organized reporting systems and real-time alerts in EHRs and CDSS. This allows staff to identify potential misdiagnoses and delayed interpretations before they harm patients. Improving communication through regular interdisciplinary sessions ensures that physicians, nurses, and other healthcare staff exchange critical diagnostic information, reducing the risk of overlooked symptoms, abnormal test results, or delayed follow-up (Hansen et al., 2023).

Hands-on training, such as scenario-based simulations focused on correct evaluation, interpretation of diagnostic tests, and structured handoff communication, enhances staff readiness and precision in high-acuity situations. Collaborative huddles among clinicians provide cooperative oversight for high-risk cases, supporting careful review and timely decision-making. Continuous audits of diagnostic procedures and patient outcomes enable organizations to identify recurring errors, address system weaknesses, and implement focused improvements. When combined with supportive leadership and a non-punitive reporting culture, these measures promote safer diagnostic practices and improve patient outcomes (Hughes, 2021).

Action Plan

One for each Root Cause/Contributing Factor from above

E / C / A

Choose one

1

To minimize communication gaps in ED settings, implement structured tools that document patient symptoms, diagnostic test orders, interpretation of results, follow-up actions, and changes in clinical status.

E

2

To address time pressures in ED, designate committed periods for staff to review and interpret diagnostic tests, patient histories, and imaging results without interruptions, while using automated tools such as EHR-integrated alerts and CDSS to streamline documentation and reduce the risk of DEs.

C/E

3

Healthcare staff participate in constant training and receive real-time alerts to ensure adherence to diagnostic safety rules and timely reporting of potential DEs.

E

First, organizational policies will be developed to emphasis the reason of DEs. This provide a designed outline to improve security and decrease risk. Second, constant professional growth and training will prepare healthcare staff with the skills to recognize high-risk scenarios and follow evidence-based diagnostic protocols (Hansen et al., 2023). This includes training in technologies and methods such as EHR-integrated alerts, CDSS, SBAR communication, and standardized diagnostic checklists. These interventions help prevent misinterpretation of test results, delayed follow-up, and other diagnostic oversights. Next, educational programs will focus on strengthening clinical confidence and readiness. This lowering the probability of misdiagnoses and improving patient outcomes (Risani et al., 2024).

Revised diagnostic policies will allocate dedicated time for staff to review patient histories, lab results, and imaging studies, while engaging in uninterrupted collaborative discussions. This ensures clinicians are mentally and physically prepared to make accurate diagnostic decisions. Moreover, continual skill support will be supported through simulation exercises and revision sessions focused on critical thinking, test interpretation, and structured handoffs. These measures aim to promote a resilient workforce capable of minimizing DEs and development a culture of patient safety, creating a safer environment for both staff and patients (Jawad et al., 2024).

The goals of the strategy include:

• Incorporate diagnostic safety alerts and high-risk patient indicators into the EHR and CDSS to identify individuals at heightened risk of misdiagnosis, enabling clinicians to review test results thoroughly and take timely, preventive actions.
• Enhance the clinical setting and technology infrastructure by organizing assessment areas, optimizing EHR dashboards, and establishing structured documentation stations to minimize the chance of missed symptoms, delayed follow-ups, or misinterpretation of diagnostic information.
• Establish comprehensive organizational policies for diagnostic safety, including standardized protocols for patient assessment, test ordering, result interpretation, follow-up procedures, and emergency responses to critical findings.
• Deliver targeted training programs on safe diagnostic practices, covering structured handoff communication, effective use of CDSS, interdisciplinary team briefings, and scenario-based simulations to strengthen staff confidence, improve preparedness, and reduce DEs in high-acuity care settings.

The desired outcomes of these efforts are to decrease DEs, improve security and results, and enhance nurses competence and confidence in accurate, evidence-based diagnostic decision-making.

Timeline
Months 1–2: Focus on developing diagnostic safety policies in collaboration with key stakeholders, including physicians, nurses, clinical leads, IT specialists, and administrators. Conduct baseline training on diagnostic protocols, critical test interpretation, communication strategies, and error reporting mechanisms.

Months 3–4: Optimize the EHR and CDSS to include diagnostic safety alerts, high-risk patient flags, and follow-up reminders. Provide staff with technical training to use these features. Initiate environmental and workflow improvements, such as organizing assessment areas, streamlining documentation stations, and standardizing diagnostic test review processes.

Months 5–6: Conduct simulation-based workshops and scenario exercises focused on accurate assessment, test interpretation, structured handoff communication, and interdisciplinary collaboration. Audit diagnostic workflows and reporting mechanisms to improve protocols based on real-time feedback and identified errors.

This strategy ensures that systems, staff, and the clinical environment are all aligned to avoid mistakes and recover security. In the final phase, regular audits, error tracking, and safety evaluations will be conducted to evaluate the efficiency of the implemented strategies and sustain improvement in diagnostic accuracy.

Suitable resources are vital for implementing a diagnostic safety program. Key personnel include experienced trainers, clinical educators, and diagnostic experts who lead staff development on accurate assessment, test interpretation, error prevention strategies, and institutional diagnostic protocols. Technical expertise is required to enhance existing EHR systems with real-time diagnostic alerts, high-risk patient flags, and follow-up reminders (Hughes, 2021). Investments in technology include CDSS, which provides evidence-based guidance, identifies contradictions, and suggests diagnostic considerations, and optimized EHR dashboards that ensure visibility of critical test results and patient trends. Financial requirements for these initiatives include approximately $35,000 for CDSS enhancements, $25,000 for EHR optimization, $3,000 for simulation-based diagnostic training tools, and $20,000 for data analytics software to monitor diagnostic accuracy, staff adherence to protocols, and patient safety outcomes over time. Leveraging existing organizational resources can reduce costs and streamline implementation.

NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Current EHR platforms can be upgraded with diagnostic alerts and decision-support features without full system replacement, with in-house IT teams managing the changes. Educators, clinical informaticists, and diagnostic leads can provide targeted training, coordinate error reporting, and oversee prevention protocols, tailoring interventions to department-specific needs and ensuring usability of safety tools. Healthcare managers and patient security officials manage budget allocations and oversee excellence development initiatives. With adequate financial investment, skilled personnel, and technological infrastructure, hospitals can establish a safer diagnostic management system that prioritizes accurate decision-making, staff skill, and patient safety (Hansen et al., 2023). National organizations such as the Centers for Disease Control and Prevention (CDC) and Agency for Healthcare Research and Quality (AHRQ) support diagnostic safety in U.S. healthcare settings through research funding, evidence-based guidelines, staff training programs, workflow audits, and integration of decision-support tools (Agency for Healthcare Research and Quality, n.d).