SIDM2020 Annual Report

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SOCIETY TO IMPROVE DIAGNOSIS IN MEDICINE OUR VISION Creating a world where no patients are harmed by diagnostic error.

OUR MISSION The Society to Improve Diagnosis in Medicine (SIDM) catalyzes and leads change to improve diagnosis and eliminate harm from diagnostic error, in partnership with patients, their families, the healthcare community, and every interested stakeholder.



Time for Solutions


Time for Partnerships


Time For Action


Time for Learning


Time to Listen to Patients


Time to Cultivate New Leaders


Now is the Time






Supporters, Sponsors, and Funders

REAFFIRMING THE IMPORTANCE OF DIAGNOSTIC QUALITY AND SAFETY LETTER FROM LEADERSHIP Even without the benefit of hindsight, we know that 2020 will forever be remembered as a year like no other. Healthcare workers, public health experts, and researchers across the world have squared off against a global pandemic that has humbled nations and jeopardized every individual. While much remains unknown, what is certain is that COVID-19 has brought stunning clarity to how essential it is to have timely, accurate, and well-communicated diagnoses. It has spotlighted the harm caused by diagnostic errors and inefficiencies throughout every aspect of the U.S. healthcare system. In SIDM’s May 14th column in The Hill, the newspaper for congressional staff and lawmakers, we noted:

” When the full history of COVID-19 is written, the opening chapter will really be about diagnostic errors on a global [scale]—our inability to evaluate, test, accurately diagnose, and communicate their diagnosis to patients as quickly as possible.” Other chapters of this terrible history will focus on the harms caused by delayed diagnosis because care was deferred or because socio-economic, racial, and other disparities led to delayed or erroneous diagnosis. Volumes will be drafted about the widespread confusion over how best to reduce COVID-19’s spread due to testing failures, material shortages, and inadequate communication. SIDM’s mission is to eliminate harm from diagnostic error. The pandemic has not diverted us from that mission; it reaffirms its urgency. The pandemic provides a stark and devastating reminder of how health systems and public- and private-sector actions and tools must support accurate, timely, and wellcommunicated diagnosis. It has shown the tragic results when they do not. Increased understanding of the role of diagnostic errors during the pandemic can spark needed change to systematically, and effectively, reduce harm. What is obvious right now is that we must work together with more fervor and clarity of purpose than ever before. The time is now. With your support, we can lead changes that are critically needed—now and in the future.

David E. Newman-Toker, MD, PhD President, SIDM Board of Directors

Paul L. Epner, MBA, MEd CEO and Co-Founder, SIDM


SOLUTIONS The National Academies of Science, Engineering, and Medicine (NASEM) in the seminal report, Improving Diagnosis in Health Care, said improving diagnosis “will require a significant reenvisioning of the diagnostic process and a widespread commitment to change among healthcare professionals, healthcare organizations, patients and their families, researchers and policy makers.” Given the dearth of tested interventions to improve diagnostic quality and safety, SIDM believes catalyzing a “bottom up” approach, where front-line health professionals and patients are engaged to develop and test interventions, will help catalyze real change. SIDM is asking questions and developing a cadre of approaches designed to improve diagnosis.

TESTING INTERVENTIONS This year, with funding from the Gordon and Betty Moore Foundation, SIDM launched the DxQI Seed Grant program and issued a call for proposals focused on quality improvement projects in diagnostic quality and safety. Seventeen programs were awarded grants of up to $50,000.



Examples of funded projects include testing interventions that seek to:



» Improve emergency department care for patients with acute dizziness/vertigo and help prevent misdiagnosis of stroke;


any of the projects M follow the Plan-DoStudy-Act (PDSA) cycle

» Create “Nuestro Diagnóstico,” a tool to engage Spanish-preferring patients and family in the diagnostic process; » Reduce delays in breast-cancer diagnosis for underserved women; » Improve diagnosis of rheumatological conditions in pediatric patients; and » Implement a new reminder tool to ensure ordered radiology tests are completed.

Kathryn McDonald leads disparities workshop at DEM2019



DISPARITIES Research demonstrates that bias can lead to diagnostic errors—which can often cause disproportionate harm to patients of color, women, children, and the elderly. Coverys has funded SIDM, initially in partnership with Stanford Medicine and now with Johns Hopkins University, to use patients’ stories of diagnostic errors due to age, race, or gender to examine specifically how the error occurred in order to offer specific implementable solutions to reduce diagnostic disparities.


OVERWEIGHING VISIBLE CHARACTERISTICS It’s definitely this other condition/disease… Lyn’s doctor saw a 50 year old, overweight woman with a history of cardiac disease and automatically assumed that she needed heart surgery.

UNDERAPPRECIATING EMERGENT SIGNS Insufficient attention and repeated dismissal of patient’s concerns, potentially influenced by assumptions tied to race or sex Jeanette’s oncologist dismissed her concerns and answered inquiries with, “You have so many questions.” She realized that when she was perceived as aggressive about her care, doctors categorized her as difficult, as they do with many AfricanAmerican patients.

OVERWEIGHING VISIBLE CHARACTERISTICS Not realizing how serious a health issue is until it’s too late, potentially related to assumptions about age Lewis’s team saw a healthy teenager in the hospital for elective surgery and discounted the warning signs of impending septic shock.




PARTNERSHIPS Experience tells us that driving real change in health care involves multi-stakeholder partnerships. Bringing together system leaders, people who have a role to play in care delivery, and patients, and their families leads to consensus, influence, and transformation. To help achieve this, the Coalition to Improve Diagnosis, convened and led by SIDM, includes leaders representing physicians; nurses; laboratory professionals; quality improvement and risk management organizations; C-Suites of health systems; accreditors; evaluators; and patients. Collectively, their expertise improves diagnosis and therefore, the Coalition is a powerful force with policymakers.

“ Although heart disease has been known for decades as the number one killer of women, the perception of it as a ‘man’s disease’ has dominated the narrative and has contributed to high rates of misdiagnosis and delay in treatment for women with heart disease. … We are excited to be part of SIDM’s Coalition to Improve Diagnosis as yet another platform to raise this issue.” Amy Friedrich-Karnik, vice president of advocacy and communications at WomenHeart

Coalition working group at their annual meeting

The Coalition members commit to the following: > Increase awareness and engagement >A dvocate for increased research funding > I dentify and drive the adoption of effective quality improvement interventions > Catalyze action by member organizations



COALITION TO IMPROVE DIAGNOSIS MEMBERS As of September 10, 2020 CLINICIAN ABIM Foundation American Academy of Pediatrics American Association of Nurse Practitioners American College of Emergency Physicians American College of Physicians Council of Medical Specialty Societies National Association of EMS Physicians National Association of Pediatric Nurse Practitioners Primary Care Collaborative Society of Bedside Medicine Society of Hospital Medicine

MEASUREMENT AND ASSESSMENT American Board of Internal Medicine American Board of Medical Specialties COLA, Inc. National Quality Forum The Joint Commission The Leapfrog Group

HEALTHCARE MANAGEMENT American College of Healthcare Executives American Society for Health Care Risk Management

INSURERS AND PAYERS Medical Professional Liability Association

HOSPITAL, HEALTH SYSTEM OR MEDICAL GROUP Advocate Aurora Health AMGA (American Medical Group Association) Ballad Health Baystate Health Children’s Hospital of Philadelphia Geisinger Intermountain Healthcare Johns Hopkins Medicine Medical University of South Carolina MedStar Health Northwell Health Penn State Health, Milton S. Hershey Medical Center The Permanente Federation, Kaiser Permanente UCSF Health University Hospitals PATIENT American Cancer Society Cancer Action Network American Heart Association Consumers Advancing Patient Safety END SEPSIS, the Legacy of Rory Staunton Sepsis Alliance WomenHeart

MEDICAL EDUCATION AND TRAINING Accreditation Council for Graduate Medical Education Alliance for Academic Internal Medicine Association of American Medical Colleges

QUALITY AND SAFETY American Health Quality Association Children’s Hospital Association ECRI Institute Health Care Improvement Foundation Institute for Healthcare Improvement Maryland Patient Safety Center Massachusetts Coalition for the Prevention of Medical Errors Midwest Alliance for Patient Safety Pennsylvania Patient Safety Authority Washington Patient Safety Coalition TESTING American Association for Clinical Chemistry American Society for Clinical Laboratory Science Association of Clinical Scientists FEDERAL LIAISONS* Agency for Healthcare Research and Quality Centers for Disease Control and Prevention Centers for Medicare & Medicaid Services Veterans Health Administration. *Views and knowledge shared by federal liaisons are limited to activities consistent with the mission of the respective federal agencies. Federal participants serving in their official capacity must not be interpreted as agency endorsement of either SIDM or the Coalition’s activities, business practices, or efforts to advocate or lobby for federal funds.




ACTION More than 30 members of the Coalition to Improve Diagnosis have signed a Consensus Statement calling on policymakers to commit more funding and resources for research on diagnostic quality and safety.

SIDM maintains regular contact with leaders in Washington to educate them about the scope and scale of diagnostic error and opportunities to reduce patient harm. We are pleased and proud that federal health agencies are sharpening their focus on diagnostic quality and safety. >F or the third consecutive year, the House of Representatives voted to increase funding for the Agency for Healthcare Research and Quality’s (AHRQ) work in diagnostic quality and safety. The Senate likely will take up this year’s measure at the end of 2020.

AHRQ accepts SIDM’s 2019 Champion for Diagnosis Award. Pictured: David Newman-Toker, SIDM; Jeff Brady, AHRQ; Gopal Khanna, AHRQ; and Paul Epner, SIDM

> A HRQ prominently featured the need for improving diagnosis throughout its patient safety publications this year, including an issue brief on Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis, an in-depth look at Operational Measurement of Diagnostic Safety: State of the Science, Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction, and an AHRQ Views blog by Jeffrey Brady, MD, MPH, titled, Using Telemedicine To Make Accurate, Timely Diagnoses: What We Still Need To Learn.

> T he National Quality Forum produced an expert panel report on measurement priorities to reduce diagnostic error and priority concepts for measure development. The report was commissioned by the Centers for Medicare and Medicaid Services (CMS) to guide the agency’s unfolding work in this area.



David Newman-Toker and Shawn Vainio, meet Sen. Lisa Murkowski (R-AK)

SIDM representatives meet at Sen. Dianne Feinstein’s (D-CA) office

> C MS also this year included prevention of diagnostic error related to the “timeliness” of diagnosis as a mandatory domain in its contracts with Hospital Improvement and Innovation Network (HIIN) quality improvement organizations.

> A HRQ is working to develop Common Formats for Event Reporting – Diagnostic Safety (CFER-DS), a resource that will assist healthcare providers to identify and report missed opportunities in the diagnostic process. Once adopted, the CFER-DS will make it possible to collect, aggregate, and analyze diagnostic safety-related information from healthcare providers across the country to accelerate learning and improvement. As part of its ongoing engagement, SIDM also made formal comments on important agency regulatory proposals, including to the Office of the National Coordinator for Health Information Technology and CMS. With support of the Mont Fund, we conducted a “Diagnostic Quality Hill Day” in conjunction with the Diagnostic Error in Medicine (DEM2019) Conference. More than 70 conference attendees signed up and received training over boxed lunches on SIDM’s messaging before heading to Capitol Hill to meet with members of their home-state delegations (60 meetings altogether). Participants carried packets of SIDMproduced “leave-behind” materials that graphically presented the enormous human and financial harms from diagnostic error, as well as opportunities to reduce those harms through improvements in research funding, quality measure development, electronic medical record functionality, and healthcare payment models.

“ AHRQ recognizes that diagnostic errors are a significant and under-recognized threat to patient safety… Working with other stakeholders to identify, promote, and efficiently implement evidencebased approaches to diagnosis is the key to success.” Jeff Brady, MD, MPH, director of AHRQ’s Center for Quality Improvement and Patient Safety (CQuIPS)





Each year, SIDM hosts the Diagnostic Error in Medicine Annual International Conference, which brings together a community of researchers, educators, patients, and policy leaders to explore the latest developments in the field of diagnostic quality and safety. In 2019, this group met in Washington, DC, to focus on the intersection of policy and diagnostic quality and safety—recognizing that public policies can create environments that support research, education, and care delivery focused on improving diagnosis. In 2019, more than 500 researchers, educators, patients, and others attended 40 sessions, reviewed more than 200 research posters, and shared their vision for a future without diagnostic harm.

ttendees at the A DEM2019 conference



Mark L. Graber presents the Mark L. Graber Diagnostic Quality Award to Gordy Schiff

My first conference. LOVED it and hope to be back. Great ideas to move the needle in our institution.

Carla Pugh speaks at DEM2019

Each session dealt with different aspects of the issues surrounding diagnostic errors and provided opportunities for people of diverse backgrounds to engage and work toward improving diagnostic errors.

DEM2019 Poster Session

A good mix of standout plenary speakers, workshops, and oral abstracts presentations. Hardeep Singh speaks at DEM2019





to Patients

The NASEM report, Improving Diagnosis in Health Care, called out the need to improve patient and family engagement in the diagnostic process. At SIDM, we strongly believe that listening to and learning from a patient’s lived experience in diagnosis and with diagnostic errors, and involving them in all aspects of what we do, is vital to achieving better outcomes that matter to patients and to reducing the harm caused by diagnostic errors.

PATIENT AND FAMILY ADVISORY COUNCILS (PFACs) PFACs serve a critical role in addressing the safety and quality of health care delivered in hospitals and health systems. They exist in institutions around the country and in some cases multiple PFACs work within a given hospital or health system, with each focused on a different population or set of issues. SIDM has identified PFACs as key partners in addressing diagnostic quality and safety—a significant but often overlooked challenge in health care. PATIENT AND FAMILY ADVISORY COUNCIL

Leaders’ Guide

for Diagnostic Quality and Safety


Guide for Hospital and Health System Leaders For Diagnostic Quality and Safety

To facilitate greater engagement of PFACs in addressing diagnostic errors, SIDM joined with the National Academy of Medicine, to host a PFAC Convening in December of 2019. PFAC representatives from around the country shared ideas to improve diagnostic quality in hospitals and health systems. Using additional insights from the Health Research & Educational Trust (HRET) Hospital Improvement Innovation Network (HIIN)/SIDM Improving Diagnosis in Medicine Change Package, SIDM produced two PFAC guides to serve as compendia of best and promising practices for use by PFACs and leadership in the hospitals and health systems in which PFACs are embedded. Each guide provides tangible ideas to tackle diagnostic quality and safety challenges. SIDM was honored to announce their release at the Institute for Patient- and Family-Centered Care’s 9th Annual International Conference.

PFAC Guides December 2019 PFAC Convening



WOMEN AND HEART DISEASE SIDM is proud to partner with WomenHeart, a member of SIDM’s Coalition to Improve Diagnosis, to help bring the patient voice to the problem of missed and delayed diagnosis of heart disease in women. The Patient-Centered Outcomes Research Institute (PCORI) funded SIDM and WomenHeart to convene a group of patients and diverse stakeholders to create research recommendations to improve health outcomes and quality of care for women with heart disease. A Steering Committee of female heart disease patients, cardiologists, nurses, researchers, policymakers, industry representatives, and others are helping to lead the planning process.

PATIENT SUMMIT Last November, as part of the Diagnostic Error in Medicine Conference, SIDM convened the 6th Annual Patient Summit focused on Reducing Cognitive Bias and Misdiagnosis Through Improved Communication. Featured speakers included Danielle Ofri, MD, PhD, Bellevue Hospital/NYU; What Patients Say, What Doctors Hear author Diane O’Leary, PhD, Rotman Institute of Philosophy, University of Maryland University College, and Jennifer Sheehy, MBA, Deputy Assistant Secretary, Office of Disability Employment Policy at the U.S. Department of Labor. Panelists joined nearly 100 patients, patient advocates, family members, healthcare professionals, students, researchers, policymakers, and others who are dedicated to patient and family engagement in improving diagnosis.

Desiree Collins Bradley speaks at the 2019 PFAC Convening

EM2019 Pedal to the Metal: D Patients as Change Makers panel





SIDM is made up of clinicians, researchers, quality leaders, patients, and families who are committed to improving diagnostic quality. But we know that support and mentorship in diagnostic research, education, and clinical practice is key to creating a culture of diagnostic quality. The SIDM Fellowship in Diagnostic Excellence program helps researchers, educators, informaticists, and quality leaders build their expertise and engagement in the field of diagnostic quality and safety. This year’s Fellows are working on projects that examine bias, stewardship of resources, communication, and medical errors through the lens of improving diagnostic quality and safety. Our previous fellows have established themselves as leaders in the diagnostic quality movement, producing peer-reviewed research, and implementing innovations in their home institutions. 2019 SIDM Fellows. Back: Gopi Astik, Grant Shafer, Julie Wright. Front: Paul Bergl (Director of Fellowship program), Irit Rachel Rasooly, Rebecca Ojo, Verity Elizabeth Schaye. Not pictured: Ali Saber Tehrani



2020 FELLOWS Justin Choi, MD, hospitalist and clinician-researcher, Weill Cornell Medical College PROJECT: Understanding group decision-making processes and the biases in the approach to diagnostic decisions of general medicine teams in teaching hospitals through ethnography, as well as developing a conceptual model to understand what factors influence teams’ diagnoses. Yasaman Fatemi, MD, pediatric infectious diseases fellow, Children’s Hospital of Philadelphia. Dr. Fatemi is working towards a Master’s of Science in Health Policy with a concentration in Healthcare Quality & Safety as part of her fellowship within the Center for Healthcare Improvement and Patient Safety, Perelman School of Medicine, University of Pennsylvania PROJECT: Developing curricula and assessment tools to understand and improve diagnostic stewardship, i.e. the appropriate utilization of diagnostic tests, and its effect on diagnostic errors. Ayodele McClenney, BSCE, JD, director of business development and strategic partnerships, Johns Hopkins University School of Medicine, Armstrong Institute for Patient Safety and Healthcare Quality, Center for Diagnostic Excellence PROJECT: Establishing Tele-Dizzy consultation, a quality improvement program using video-oculography goggles to improve diagnosis of acute dizziness and stroke, and assessing its impact at Howard County General and Sibley Memorial hospitals. Rajasekhara Mummadi, MD, chief of quality and population health and gastroenterologist, Northwest Permanente, P.C. PROJECT: Studying the implementation and effectiveness of communication of critical imaging results directly to patients from the Kaiser Permanente Central SureNet monitoring system. Varun Phadke, MD, assistant professor, Division of Infectious Diseases, Emory University School of Medicine PROJECT: Developing a framework for the cognitive processes used by subspecialists in patient care as they make diagnoses, and developing metrics of consultative care that could be used for assessment and remediation of learners, quality improvement, and a more cohesive understanding of errors. Lisa Schwartz, MD, MSc, assistant clinical professor and hospitalist, Internal Medicine Teaching Service, NYU Langone Hospital - Brooklyn. PROJECT: Developing a Diagnostic Certainty Tool within the medical record to track diagnostic reasoning and ultimately educating users on diagnostic uncertainty, missed diagnoses, delayed diagnoses, and diagnostic error. Viralkumar Vaghani, MBBS, MPH, MS, healthcare informatics analyst, Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine and Michael E. DeBakey Veteran Affairs (VA) Medical Center PROJECT: Developing, testing, and validating SaferDx Trigger Tool Framework based e-trigger algorithms using EHR data to identify missed opportunities to diagnose certain conditions in primary care. SIDM 2020 ANNUAL REPORT


NOW IS THE TIME Paul Epner, in an opinion piece in The Hill noted, “The diagnostic errors we are experiencing in relation to the COVID-19 pandemic are a major concern but are not unique. Our healthcare systems may be the most advanced in the world, but the diagnostic process is complex and error-prone. Five years ago, the NASEM report, Improving Diagnosis in Health Care, designated diagnostic errors to be an urgent public health concern, one likely to affect each of us in our lifetime.� COVID-19 has caused many of us to adapt the work we are doing in response to an unprecendented public health crisis. Communities have come together to support clinicians and patients as they navigate the changing science, testing, and public health recommendations. In our COVID-19 Dx IQ column, we help patients understand the strengths and limitations of the different modalities of testing for COVID-19. SIDM has also provided a clearing house of Coalition resources related to the pandemic.



Funders recognize that work needs to be done to help researchers, clinicians, and patients adapt to the changing healthcare landscape as a result of COVID-19. The pandemic has made everyone aware of the challenges in diagnostic quality and it has transformed the way care is being delivered. For example, COVID-19 has skyrocketed the use of telemedicine overnight, establishing it as a mainstay for healthcare delivery and diagnosis. What does that mean for diagnostic quality and safety? SIDM, with funding from PCORI, is convening a series of conversations about TeleDx research priorities. “Learning While We Build: Identifying the Must-Know Research Questions for Safe and Effective Telediagnosis” will bring together a multistakeholder group including SIDM’s Patient Engagement Committee, WomenHeart, Sepsis Alliance, American Telemedicine Association, Advocate Aurora Health, Council of Medical Specialty Societies, Digital Medicine Society, Teladoc Health, and others to make recommendations on the research most needed by the field. Understanding research questions important to patients, as well as other stakeholders, will be a crucial element of this work.

Diagnosis, SIDM’s peer-reviewed scientific journal, has published more than a dozen articles and editorials focused on the unique diagnostic challenges of COVID-19.



OUR BOARD David E. Newman-Toker, MD, PhD, President

Helen Burstin, MD, MPH

Tom S. Lee, PhD, MBA

Robert Trowbridge, MD, President-elect

Jen Campisano, JD

David L. Meyers, MD, FACEP

Timothy J. Mosher, MD, Secretary

Beth Daley Ullem, MBA

Doug Salvador, MD, MPH

Edward Hoffer, MD, Treasurer

Gurpreet Dhaliwal, MD

Dana Siegal, RN, CPHRM, CPPS

Paul L. Epner, MBA, MEd (Ex-officio), Chief Executive Officer


Ronald Wyatt, MD, MHA

STAFF Paul L. Epner, MBA, MEd, Chief Executive Officer Gerard M. Castro, PhD, MPH, PMP, Director of Quality Improvement


Suz Schrandt, JD, Senior Patient Engagement Advisor Penne Silverman, Chief of Staff and CFO

Ilse Garcia Romero, Marketing and Communications Associate

Lorie Slass, Vice President of Marketing and Communications

Tina Huff, Corporate Partnerships and Engagement Manager

Jeremiah Smith, Program Assistant

Stacia Russell, Finance Manager

Leslie Tucker, Senior Policy Advisor


Amanda Staller, Digital Content Manager


FY 2018

FY 2020*

FY 2019
































FY 2018

FY 2020*

FY 2019

























* Unaudited results ** Excludes investment income






4.0M 3.5M


5M 3.0M 4M





2.0M 1.5M



1.0M 1M



FY 2017

FY 2018

Unrestricted Net Assets

FY 2019

Restricted Net Assets

Individual Giving


FY 2020* FY 2017

FY 2018

FY 2019

FY 2020*

Organizational Grants & Giving Foundations FY 2017

FY 2018

Contract Services


FY 2019


FY 2020*


SUPPORTERS, SPONSORS and FUNDERS Consider Supporting SIDM’s Important Work SIDM is the only organization focused exclusively on reducing diagnostic error in medicine. Through awareness, outreach, dialogue, research, and education, SIDM sets the quality and safety agenda for improving diagnosis. It is through our funders, corporate partners, health institution supporters, and individual donors that we are able to continue our work to improve diagnostic quality and safety. SIDM is a 501(c)(3) non-profit organization. Your financial support is tax-deductible to the extent allowed by the IRS. When you support SIDM, you help lead the way to better health care for everyone. Thank you for your generosity.

GRANTORS AND PROJECT PARTNERS (current and multi-year projects) Agency for Healthcare Research and Quality Constellation Coverys Community Healthcare Foundation Gordon and Betty Moore Foundation Jewish Community Foundation of Southern Arizona

The Human Diagnosis Project Josiah Macy Jr. Foundation Patient-Centered Outcomes Research Institute PCPI Foundation WomenHeart

CORPORATE, HEALTHCARE INSTITUTIONS AND NONPROFIT MEMBERS (as of June 2020) $10,000 and above Isabel Johns Hopkins Armstrong Institute Center for Diagnostic Excellence VisualDx $5,000-$9,999 Advocate Aurora Health American Association of Nurse Practitioners Constellation Covera Health Coverys Community Healthcare Foundation CRICO Physicians’ Reciprocal Insurers The Permanente Federation, Kaiser Permanente $2,500-$4,999 AcademyHealth American Board of Medical Specialties COLA, Inc. MCIC Vermont NBME



$1,500-$2,499 American Medical Group Association Association of American Medical Colleges Integrated Project Management Company Intermountain Healthcare MedStar Health Under $1,500 Alliance for Academic Internal Medicine Massachusetts Coalition for the Prevention of Medical Errors National Association of Pediatric Nurse Practitioners Sepsis Alliance Society of Bedside Medicine

LEARN MORE Become a corporate, healthcare institution, or nonprofit member and help us catalyze and lead change to improve diagnosis and eliminate harm from diagnostic error.

INDIVIDUAL DONORS Guardian $10,000+ Anonymous The Mont Fund New World Somewhere Leader $5,000-$9,999 Michael Armstrong Paul L. Epner and Janet Gans Epner Peter T. Robertson Sue Sheridan Penne and John Silverman Patron $2,500-$4,999 Beth Daley Ullem Gurpreet Dhaliwal David L. Meyers and Roberta Strickler Timothy J. Mosher David Newman-Toker Jack and Renate Schuler Robert Trowbridge Jeffery Winston Sustainer $1,200-$2,499 Carmel Crock Steve and Louise Epner David Hunt Mamatha Panacholi Gordon D. Schiff Season of Change Foundation Benefactor $600-$1,199 Anonymous Kerin Bashaw Helen Burstin Jennifer Campisano Karla Dick Marc and Marci Epner Antonio Garcia Raminder Gill Robert Greene Edward Hoffer The Triple EEE Foundation Tom S. Lee Dan Mayer Patrick McCabe Carrie E. Nelson

Carla Pugh Doug Salvador Christopher Sankey Kurt Zumwalt Supporter $300-$599 Anonymous John Astle Richard A. Beck Paul Bergl Denise Bockwoldt Michael A. Bruno Christine Bryson Janet Buckstein Paul Buntine Leslie Castaneda Robert Centor Jennifer Chang Maureen Clark Denise Condron John Cuddeback John Cunningham Michelle Daniel Anne Dean Catherine Derber Bradley DeVrieze Michael Dobson Al Duke Alex Dummett Robert El-Kareh Patrick Fadden William Follansbee Ethan Fried Andrew Georgiou German Giese Heather Gocke Sandip Godambe Christine Goeschel Randy A. Goldberg Mark L. Graber Robert M. Hamm Harry Hoar Eric Holmboe Hiroshi Imura Gerrit Jan Jager Sugeet Jagpal Bimal Jain Cynthia Johnson Narinder Kapur Rabindra Katwal Peter Kennedy Janice Kwan Deb Leach Tsung-Shung Harry Lee Jeff Leman Diane L. Levine

Roberta Camille Locko Avram Mack Marisa Magiros Andrew J. Majka Gerald Maloney Silvia Mamede Janet Mangun Kyle Marshall Beth Martin-Kool Kimberly McCoy Lynn McKinley-Grant Robert Means, Jr. Ashley N.D. Meyer Chad Stephen Miller Yasushi Miyata Rajasekhara Mummadi Balkrishnan Nair Kevin O’Leary Michael Perry Charles A. Pilcher David Pincus Melissa Plesac James Poitras Stephen Priestley Elizabeth A. Regan Peter Rudd Richard Ruddy Ruth Ryan Melchor Sanchez Lauren Sanders Paula Santrach James Schneider Karen Schoelles Lisa Schroeder Jasna Seserinac Lee Shapiro Manish Sharma Donald Lawrence Sherak Hardeep Singh Lorie Slass David Smallwood Brent Smith Sheila Smith Edith ter Braak Dennis Torretti Owen Traynor Melinda Truesdale Robert van den Berg Amanda Walker Julianne Nemes Walsh Thilan Wijesekera Roger D. Wilson Edward Winslow

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Mohamud Daya Theo de Malmanche Marie DeFrances Leandro Arthur Diehl William Dillin Deborah Dinardo Laurie C. Drill-Mellum Karen Dunn Nicholas Dupuis John W. Ely Helena Esmonde James Fackler David Feldman James Feldman Jonathan Fliegel Rebecca Forrestor Phil Foulis Beth Fox James Walter Fox Hamish Fraser Adam Friedlander Katherine Frishe Ann Gaffey Doug Gallagher Ellie Garbade Morey Gardner Muhammad Husnain Ghazanfar Traber Giardina Daniel Gluckstein Megan Golden, Mission:Cure Patricia Griffith Daniel Paul Groszkruger Joseph A. Grubenhoff Ashwin Gupta Michael Handler Curtis Hanson Gene Harkless Julia Harrison Paul Harvill Matthew Hawks James Hildebrandt Timothy W. Holder Lewis Holmes Eduardo Hornos Barberis Jonathan Housman Lisa Howley Wolfgang Huf Mimi Hugh Dan Hunt Kunimitsu Inoue Linda M. Isbell Masayuki Iyanaga Arif Jan



Mark Jarrett Rebecca Jones Aaron Kalinowski Tetsumasa Kamei Bridget Kane Michael Kanter Kelly Kelleher Katherine Killian Michael Klass Sharon Kletchko Jeffrey Kline Hans Krabbe David Kudlowitz Luqman Arafath Thazhathuveetil Kunhahamed Ifedayo Kuye Andrew Lai Farhan Lalani Steven Langer Susan Leclair Chinmei Lee Stefanie Lee Michael Legg Gregory Lehman Juan N. Lessing Mark Linzer James Liszewski Keith Littlewood David Lockman James Loeffelholz Ronald Loo Jennifer Lopez Robert Lowe Eve Judith Lowenstein Prashant Mahajan Dahlia Mak Edward Jay Malone Courtney Mangus Eric Marks Trisha Marshall Stephen Martin Christopher Mathews Ayodele McClenney Keith McNellis Helmut Meisl Marcio Melo Krishan Mohindroo Laurin Beth Mooney Abraham Morse Randal Moseley



Virginia Moyer John Murphy Arthur Nahill Ross Nicholson Susan Nofziger Evan Oakes Joanna Offord Willie H. Oglesby Adedotun Ogunsua James F. Oldham Maria Olton Laura O’Neill Kumiko Orimoto James Oswald Thomas Painter Rick Panning Jeanann Pardue Gopi Patel Vinay Patel Mark Perdue Luke Perkocha Carol Peters Benjamin Pflederer James Philson Jorge Horacio Portillo Gallo Mary Prinzing Michael Pulia Katie Raffel Willie Rainey Kimberly Rask Negar Rassaei Kathleen Rea Joseph Rees Laura Rife Tomie Rogers Rico Romano Edwin Rosas Leon Rosenkranz Dennis Rouw Jack Myron Rubenstein Matthew Rubinstein Cym Anthony Ryle David Ryon Stephen Sandroni Barbara Sanford Marcus Scarbrough Verity Schaye Christine Schmotzer Stephen Schoenbaum

James Schultz L. Bradley Schwartz Don Scott Melania Scrace Ayan Sen Kamalesh Shah Wilson Shcolnik Keith Shenberger Raphael Sherak Dana Siegal Aaron Silver Catriona Susan Slater Kathy Smith Kelly Smith Sharon Snyder Frederick Southwick Steve Stanfield Thomas Stanis Keith Starke Dale Steele Dawn Steiner Ron Sultana Kathleen Sweeney Robert Swerlick Bizath Taqui James Taylor Stefan Tchernodrinski Maarten ten Berg David Theige Marjorie Thomas Paul Tibbits Brett Todd Nelson A. Toussaint Eleanor May Travers Paul F. Treder Justin Tse Cyruss Tsurgeon Sean Uiterwyk Tamas Ungar Maarten Van Aken Lois VanEnk Antonio Vaz Carneiro Constanza Villalba John Vinen Jason Waechter Andrew Walby Yunxia Wang Dane C. Warner Satoshi Watanuki Chase Webber Diane Webster Saul N. Weingart

Adrianne B. Wesol Ira Williams Karen Woys Jean Wright Daniel Yang Umamahesh Yellamraju Paul Yip Lawrence Yuen Laura Zwaan Friend/Resident/ Student Up to $149 John Alexander Lorenzo Alonso Carrion Trish Anderson David Andrews Kimberly Applegate Gopi J. Astik Fouad Atallah Matt Austin Michael Avesar Martin and Ginelle Bader Zachary Bauer Robert Berenson Jerry Both James Boyle Danielle Buck Charles Burger Thomas Campbell Lannie Cation Keith Chaitoff Matthew Clark Yvonne Covin Carlo Giovanni Doroldi Helene Epstein Irene Fuller Michael Futrell Jeff Galowich Ali Ghobadi Robin Gilson Bradley Goettl Darren Golde Jessica Graham Sana Grant Allan Grogan Ayse Gurses Elizabeth Harmon Helen Haskell Brittany Hay

Jennifer Hayes Robert Hirschfeld Tina Huff Lisa Juliar Joseph G. Keary Shannon Kern Sadid Khan Benjamin LaHood Marius Laurent Shin Jey Lee Yen Ching Peggy Lee Austin Lee Sydney Lee Kim Matsumoto Barry McKeown Douglas McKrll Jo Meleca-Voigt Traian Mihaescu Scott Nass Gabrielle Nolle Melinda Oler Jack Penner Ari Perlin Randy Phillips, Jr. Lauren Powell Eileen Pummer Kathryn Reback George Reigeluth Steven Roy Matthew Sakumoto Conrad Schuerch Grant Shafer The Smith-Cooper Family Thomas Syzek Danny Van Leeuwen Chesinta Voma Thomas Westover Maureen Williams Cecily Wiswall Anes Yang Rommel Gerardo Zerpa Alamo Cindy Zhang Tammy Zinsmeister

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“It   is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.� National Academies of Sciences, Engineering & Medicine