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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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