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It’s time for national policy that puts diagnostic safety on the agenda, and drives real change to prevent errors before more patients are harmed, write Laura Chien, Mary Dahm and Jen Morris.
Every year in Australia, an estimated 140 000 people experience a diagnostic error. For 21 000 people, it causes serious harm. For 4 000 people, it’s fatal. These errors cost our health system an estimated $44.2 billion annually, 17.5% of total healthcare spending. That’s close to the entire NDIS budget.
The staggering personal and economic burden of diagnostic error is particularly hard to accept because around 80% of this harm is preventable. Yet this critical patient safety issue remains largely unaddressed in Australia — a situation which is not acceptable or justifiable, given the scale of the problem.
Right now, there is a rare opportunity for change. The Australian Commission on Safety and Quality in Health Care is currently developing the third edition of Australia’s National Safety and Quality Health Service (NSQHS) Standards. The NSQHS standards set what safe, quality healthcare looks like and what health services must do to protect patients from harm. The Commission has asked stakeholders to identify existing and emerging safety and quality risks it should consider including in the third edition. The Commission has a once-in-a decade opportunity to embed comprehensive requirements for diagnostic safety into these standards. Doing so would position Australia as a global leader in diagnostic safety, preventing a major source of avoidable patient harm and death.
Diagnostic safety — what it means for patients and clinicians
Diagnostic safety focuses on preventing diagnostic errors: diagnoses that are delayed, missed or wrong. These errors happen when the process fails to provide an accurate and timely diagnosis, or when the diagnosis, and any associated uncertainty, are not properly communicated to the patient.
Diagnostic safety means ensuring safe, quality care throughout the entire diagnostic process. The diagnostic process starts when a patient first accesses healthcare. It involves working with the diagnostic team who gather, interpret and integrate information to reach a timely diagnosis and communicate that diagnosis to the patient to start treatment.
Diagnostic safety on the world stage
Globally, diagnostic safety is increasingly recognised as an urgent patient safety priority. The diagnostic safety movement began gaining traction in the US around the mid-late 2000s driven by the former Society to Improve Diagnosis in Medicine. That movement was sustained via federal funding for diagnostic safety research through the Agency for Healthcare Research and Quality and philanthropic organisations. In 2015, the US National Academies’ landmark report Improving Diagnosis in Health Caredeclared it “a moral, professional, and public health imperative” to improve diagnosis. Diagnostic error topped ECRI’s list of top-10 most pressing patient safety concerns in 2018, and diagnosis-related issues featured prominently in 2025. Diagnostic error was the theme chosen by the World Health Organization for the 2024 World Patient Safety Day, recognising it as a global public health priority, and calling on countries to act. The WHO’s Global Patient Safety Action Plan 2021-2030 calls on governments and healthcare services to assure the safety of every clinical process, including measuring incidence rates and reductions in missed or delayed diagnosis.
Australia’s diagnostic safety gap
While international momentum builds, Australia is falling behind. Australian diagnostic error experts have called for healthcare organisations to establish diagnostic safety programs, predicting that “health service standards will likely come to include specific diagnostic safety standards”. That prediction has not yet eventuated. There is a significant diagnostic safety policy vacuum in Australia and New Zealand compared to the US, with diagnostic safety being rarely mentioned in our healthcare policies. We lack national data on the scale and impact of diagnostic error. Without it, we can’t answer the WHO’s call to measure and reduce missed or delayed diagnoses. We simply don’t systematically record or report on diagnostic error. Without national standards driving coordinated action, efforts to improve diagnostic safety will remain slow, ad hoc and under-resourced. Australians deserve better.
A once-in-a decade opportunity
Diagnostic safety can’t remain a patient safety blind spot in Australia. We’re calling on the Commission to include diagnostic safety as a standalone standard in the third edition. A standalone standard would increase awareness of diagnostic safety as a preventable systemic safety concern, and put it on equal footing with well-established patient safety domains like medication safety, infection control and acute deterioration. This inclusion would also match the prominence of the issue to the scale of harm from diagnostic safety issues, and to health services’ ability and responsibility to address it.
A standalone standard would challenge two dangerous misconceptions about diagnostic error that are holding back progress. First, that diagnostic error is an individual clinician’s failing, rather than a system safety issue: diagnostic errors arise from system failures that health services can and must address. Second, that diagnostic error is an unavoidable and inevitable part of healthcare. It’s not — the vast majority of diagnostic errors are preventable.
Including diagnostic safety as a standalone standard would be a world first, driving transformational change in patient safety. It would send a clear signal to the healthcare community, here and internationally, that health services have the responsibility and ability to address diagnostic safety.
Such recognition would foster genuine cultural change. It would create far-reaching awareness, and move us from an outdated ‘name, blame and shame’ approach that serves nobody’s interests, toward a comprehensive, systems-based, evidence-informed approach that saves lives, prevents suffering, reduces costs and builds a better healthcare system for everyone.
The Monash Medical School Symposium on Improving Diagnosis will take place at Monash University Clayton Campus on 15 December 2025. Convened by Associate Professor Carmel Crock OAM, Associate Professor Nicola Cunningham, Associate Professor Julia Harrison and Chloe Lacey, the symposium theme is ‘The Art and Science of Diagnosis’. Dr Mary Dahm, Jen Morris and Laura Chien will deliver a symposium workshop on communicating uncertainty to enhance diagnostic excellence.
Laura Chien is a PhD Candidate at the ANU Institute for Communication in Health Care and US Institute for Healthcare Improvement Fellow 2024-25. Her research investigates the communication of diagnostic uncertainty from the perspective of patients and caregivers to support safe diagnosis in emergency care.
Dr Mary Dahm is a Senior Lecturer in Health Ethics and Professionalism in the School of Medicine at Deakin University. Her research focuses on investigating the impact of health communication in quality and safety of care. She is a leader in the field of diagnostic communication and currently holds an ARC DECRA fellowship investigating the critical role and impact of communication on the diagnostic process in health settings.
Jen Morris is a patient safety advocate and healthcare user representative working with health sector organisations to prevent patient harm, with a particular focus on diagnostic safety. In 2024 she was inducted into the Victorian Honour Roll of Women for her outstanding service to patient safety.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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It goes without saying that the correct diagnosis is the gateway to both the correct treatment plan and assists the building of trust with the patient and loved ones. We know that the failure to get this right leads to preventable patient harm.30 years ago we identified this problem in the publication of the Quality in Australian Healthcare Study, and the problem has quite possibly got bigger in the interim, as more time is spent ordering and reviewing test results and less time actually listening to and examining the patient. And time is an increasingly scarce commodity in clinical practice. This change in the context of care delivery, of the changes in the healthcare “system”, is a vital piece in understanding how to address the harm from diagnostic error. In the broader discussion of improving the quality and safety of healthcare, we have been tempted by the easier and short term initiatives. This has led to insufficient efforts to address the larger system issues, and hence not as much improvement in performance as we would want and need.
The Australian Commission for Quality and Safety in Healthcare has a vital role here, in straddling the tension between creating enough focus on diagnostic harm without losing the necessary integration of all the other efforts to continuously improve the quality and safety of healthcare for our patients
In my research field of Delirium, underdiagnosis is common and causes poor outcomes.
Diagnostic Radiologists in Private Practice are paid mainly by a % of the fee for each case. Owners of the Practice/business have an obsession with workflow, throughput, daily gross income, and margins.
This combination creates a ‘perfect storm’ to do higher throughput, more cases and generate more retained income every day.
Many examinations are completed by the staff, and patient has departed before a Radiologist has even seen the request…to be able to appropriately ‘tailor’ or amend the examination….let alone talk to the patient…or referring doctor.
In such an environment errors and waste are inevitably increased…
It is lovely to note how diagnostic error becomes that much more clear in hindsight, helping to drive, for instance, the relative ease of formulating a Plaintiff case in tort law (not that we should all now be looking over our shoulder, in the rear view mirror).
Would that everyday clinicians had this outcome knowledge ability up front at the bedside.
And of course Medicine, based on the importance of the humanity-first approach to patient care, with an ubiquitous lack of good evidence in so many areas, and or medical reversal where what we thought is no longer, is always going to be shrouded in uncertainty.
Surely this is what makes the ‘art’, not ‘science’, of Medicine so challenging, and so rewarding to get right?