Diagnostic Error: A Patient Safety Imperative

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Rebecca Jones, MBA, BSN, RN, CPHRM, CPPS

Rebecca Jones is Director of Innovation and Strategic Partnerships at the Pennsylvania Patient Safety Authority. In this capacity, she leads the Authority's innovation efforts, oversees its infection prevention and project management teams and collaborative programs, and develops and maintains relationships with key strategic partners.

Ms. Jones also established and serves as Center Director for the Authority's Center of Excellence for Improving Diagnosis, which provides leadership, guidance, and support for health care facilities and systems, providers, patients, and all interested stakeholders to decrease harm from diagnostic error.

Prior to her current roles, Ms. Jones served as Special Assistant to the Executive Director, establishing the Authority's innovation plan and strategic goals and objectives for its programs. She joined the Authority in 2015 as a Regional Patient Safety Liaison, working directly with more than 80 Pennsylvania healthcare facilities to improve patient safety through education, collaboration, and analysis of reported events. Prior to her work with the Authority, she served in various roles leading patient safety efforts and proactively managing risk in healthcare organizations.

Ms. Jones graduated summa cum laude and was awarded the Elizabeth F. Wagoner Nursing Medal from Immaculata University and earned her Master of Business Administration degree in Healthcare Management from Western Governors University. She is a registered nurse, Certified Professional in Patient Safety, and Certified Professional in Healthcare Risk Management. She has written publications for the American Society for Healthcare Risk Management focused on second victims and managing the risk of human error. She also is Co-Chair of the Nurses and Diagnosis Community of Practice, serves on the Advisory Committee of the Coalition to Improve Diagnosis, and is a member of the Practice Improvement Subcommittee of the Society to Improve Diagnosis in Medicine.

Timothy J. Mosher, MD

Timothy Mosher is the Kenneth L. Chair, Department of Radiology at Penn State University and Distinguished Professor of Radiology and Orthopaedic Surgery. Dr. Mosher is active in the field of diagnostic error in medicine serving as a member of the Board of Directors for the Society to Improve Diagnosis in Medicine (SIDM) and as a representative of Penn State Health in the Coalition to Improve Diagnosis. He is the Physician Advisor to the Pennsylvania Patient Safety Authority Center of Excellence for Improving Diagnosis. Dr. Mosher is a clinical musculoskeletal radiologist at the Penn State Hershey Medical Center with a particular interest in musculoskeletal MRI. Dr. Mosher is a fellow of the International Society for Magnetic Resonance in Medicine. He is an Associate Editor for MRI for the journal Radiology. He is a standing member of the SBSR/NIH study section. Dr. Mosher has published over 70 books and manuscripts with the majority in the area of musculoskeletal imaging, quantitative cartilage imaging, and MRI technical development.



  • Develop a working definition of the term “diagnostic error”
  • Identify system and cognitive factors that contribute to risk for diagnostic error
  • Describe areas of opportunity for improvement to reduce the risk of diagnostic error
  • Identify the key objectives of the Pennsylvania Patient Safety Authority’s Center of Excellence for Improving Diagnosis


Diagnostic errors are a complex and often overlooked problem in the field of patient safety. While various cognitive and system factors contribute to the problem, there are many opportunities for improvement.

This session explores how the Pennsylvania Patient Safety Authority’s newly formed Center of Excellence will work to improve diagnosis in Pennsylvania.

Presentation: 1:00:38