Policy and Practice Impacts

The innovations generated by the Safer Dx team have impacted policy and practices at both the VA and other healthcare organizations.

VHA Directive 1088: Communicating Test Results to Providers and Patients

Dr. Singh co-led and worked with the Office of Primary Care on revising VHA Directive 1088 on communication of test results which requires VA providers to communicate normal test results to patients within 14 days after the result becomes available or within 7 days when results require follow-up action. This national policy released in July 2023 sets standards related to the timeliness of test results communication and informs a performance measurement and quality improvement program implemented across the entire VA healthcare system. This directive was informed by the Safer Dx team’s work on missed test results.

Computerized Patient Record System (CPRS) View Alert Notification Checklist

The Safer Dx team created this checklist for the VA to help clinicians and staff manage alerts in the EHR system. It was disseminated to all VISN directors and Chief Medical Officers in 2017. 

10 Strategies for Managing Notifications

This training document was created by the Safer Dx team and distributed to all VA facilities for CPRS training.

National and International Reports

The Safer Dx team’s work has informed:

• The American Medical Association (AMA) report Research in Ambulatory Patient Safety 2000-2010: A 10-Year Review (2011) was informed by 9 Safer Dx publications.
• The Institute of Medicine report Health IT and Patient Safety: Building Safer Systems for Better Care cited 4 publications from the team.
• The National Academies of Sciences, Engineering, and Medicine (NASEM, formerly the Institute of Medicine) report Improving Diagnosis in Healthcare (2015) cited 33 publications from the team.
• The National Health Service (NHS) guidelines Standards for the Communication of Patient Diagnostic Test Results on Discharge from Hospital (2016) cited 1 publication from the Safer Dx team.
• The World Health Organization (WHO) report Patient Safety In Primary Care (2016) was co-authored by Dr. Singh and cited 11 publications from the team.
• The ECRI and Partnership for Health IT Patient Safety report Health IT Safer Practices for Closing the Loop (2018) cited 13 publications from the team.
• The Organization for Economic Co-operation and Development (OECD) report The Economics of Patient Safety in Primary and Ambulatory Care (2018) cited 4 Safer Dx publications.
• The WHO report Patient Safety and Risk Management Service Delivery and Safety (2019) was informed by 2 publications from the Safer Dx team.
• The National Quality Forum (NQF) report Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations (2020) cited 10 publications from the team.
• The National Academy of Medicine (NAM) special report Health Data Sharing to Support Better Outcomes: Building a Foundation of Stakeholder Trust (2021) cited 1 publication from the Safer Dx team.
• NASEM proceedings Achieving Excellence in the Diagnosis of Acute Cardiovascular Events: Proceedings of a Workshop in Brief (2021) cited 1 publication from the team.
• The NAM report Implementing High-Quality Primary Care (2021) was informed by 1 Safer Dx publication.
• The Joint Commission’s Sentinel Event Alert Diagnostic Overshadowing Among Groups Experience Health Disparities (2022) cited 2 publications from the team.
• The WHO report Implications of the COVID-19 Pandemic for Patient Safety: A Rapid Review (2022) was co-authored by Dr. Singh and cited 9 publications from the team.
• The AMA publication Reports of the Council on Science and Public Health (2022) cited 1 publication from the Safer Dx team.
• The NASEM report Achieving Whole Health: A New Approach for Veterans and the Nation (2023) cited 2 Safer Dx publications. 
• The NAM report Emerging Stronger from COVID-19: Priorities for Health System Transformation (2023) was informed by 1 publication from the Safer Dx team.
• The WHO Global Patient Safety Report (2024) was informed by 7 publications from the team and Dr. Singh contributed a featured story.
• Dr. Singh was invited to serve on the WHO Drafting and Review Task Force for the Global Patient Safety Action Plan 2021-2030. 
• Dr. Singh was invited to serve on the WHO World Patient Safety Day 2024 Steering Committee and the Planning Group. 
• The President’s Council of Advisors on Science and Technology released its finding on patient safety in a report to President Joe Biden entitled “A Transformational Effort on Patient Safety” that cited 2 publications from the Safer Dx team (PMID 30395508 and PMID 24742777). The report outlines recommendations to advance the nation's commitment to supporting robust safety solutions for patients and the healthcare workforce.