Project RedDE!

Toolkit for Reducing Diagnostic Errors in Primary Care - Project RedDE!

Toolkit Overview

The Reducing Diagnostic Errors in Primary Care Pediatrics (Project RedDE!) Toolkit aims to assist primary care practice teams with a systematic approach to reduce diagnostic errors and improve care for children. This toolkit will walk teams through the measurement, screening, recognition, diagnosis, follow-up, and reduction of diagnostic errors associated with pediatric elevated blood pressure, adolescent depression and laboratory testing through improvement science methods. Funding for the Project RedDE! and this toolkit has been provided by the Agency for Healthcare Research and Quality.   

This toolkit is based on clinical evidence, best practices, and is a compilation of resources from Project RedDE! which involved over a hundred primary care physicians and their care teams working across the United States to improve care for children. By using this toolkit, primary care providers will be able to:

  • Learn how to implement a systematic approach to providing safe and quality care to your patients   

  • Test strategies for improving care  

  • Access tools and best practice from national experts 

  • Reduce the likelihood of patient harm by identifying and decreasing diagnostic errors

Blood Pressure​​​



Introduction to Project RedDE!

Despite being identified in 1999 in ‘To Err is Human’ as a central facet of patient safety,1 diagnostic errors (missed, delayed or incorrect diagnoses) remain understudied2 Diagnostic errors cause appreciable patient harm,3 and their reduction lags behind advances in other patient safety areas.4,5  Limited pediatric-focused research on diagnostic errors highlights the significance of this problem in children: 

  • Fifty four percent of pediatricians report making diagnostic errors at least monthly and 45% report making harmful diagnostic errors at least annually.6 

  • Errors in diagnosis were the most prevalent error type in closed pediatric malpractice claims.

  • Evidence from adult and pediatric primary care settings suggest diagnostic errors are harmful and involve a variety of diseases.5 

Few studies rigorously investigate diagnostic error reduction efforts and even fewer focus on children.5 More research on interventions to prevent pediatric diagnostic errors is needed.  Project RedDE! aimed to help improve care for children while increasing the knowledge base around diagnostic errors in pediatrics.


Results from this quality improvement collaborative indicated that improvements in diagnostic error rates can be achieved by utilizing a wide range of tools and resources to implement best practices.  The results are now published in the Pediatric Quality & Safety journal, and can be accessed here:

  1. Rinke ML, Bundy DG, Stein REK, O’Donnell HC, Moonseong H, Sangvai S, Lilienfeld H and Hardeep S.  Increasing Recognition and Diagnosis of Adolescent Depression: Project RedDE; A Cluster Randomized Trial, Pediatric Quality & Safety: September 30, 2019. doi: 10.1097/pq9.0000000000000217

  2. Rinke ML, Bundy DG, Lehmann CU, Moonseong H, Adelman JS, Norton A, and Singh H.  Project RedDE: Cluster Randomized Trial to Reduce Missed or Delayed Abnormal Laboratory Value Actions.  Pediatric Quality & Safety: September 30, 2019. doi: 10.1097/pq9.0000000000000218

  3. Rinke ML, Singh H, Brady T, Moonseong H, Kairys SW, Orringer K, Dadlez NM, and Bundy DG.  Cluster Randomized Trial Reducing Missed Elevated Blood Pressure in Pediatric Primary Care: Project RedDE.  Pediatric Quality & Safety: September 30, 2019.  doi: 10.1097/pq9.0000000000000187

    Project RedDE! Research Model

    ​Project RedDE! used a multisite, prospective, stepped-wedge, cluster randomized trial to test if a quality improvement collaborative could reduce the incidence of pediatric primary care diagnostic errors. The quality improvement collaborative model engaged a total of 31 practice teams throughout the United States and employed a combination of evidence-based best-practice methodologies, mini-root cause analyses, data sharing, and behavior change techniques. Teams were randomized to work to reduce one diagnostic error while serving as a control for a second diagnostic error and acted as a control for a third. Finally, all teams worked to reduce all 3 diagnostic errors. In this way, Project RedDE! examined not only if teams could reduce diagnostic errors, but whether this reduction could be sustained as teams began working on other, equally important factors. 

    This project focused on three specific, high-risk, ambulatory diagnostic errors each representing a unique dimension of diagnostic assessment: evaluation of symptoms, evaluation of signs and follow-up of diagnostic tests. The goal of the project was to reduce diagnostic errors by tracking error rates (outcomes measures) and reliably perform best practices for diagnosing: 

    Clinical Trial Registration: Reducing Diagnostic Errors in Primary Care Pediatrics (Project RedDE!), NCT02798354

    Project RedDE! Conceptual Model

    ​Through the quality improvement collaborative, Project RedDE! employed a conceptual model which involves screening, recognition, and diagnosing each clinical condition to prevent diagnostic errors:

    ​Adolescent Depression​Was patient screened for depression?​Did the provider document adolescent depression concerns or the exclusion of adolescent depression concerns?​Does the patient have documentation of major depression, dysthymia or sub-syndromal depression as part of the problem list, assessment, or billing record?
    ​Pediatric Elevated Blood Pressure​Was patient screened for elevated BP?​Did the provider document the blood pressure percentiles?

    Did the provider document that the blood pressure was elevated?
    ​Did the provider take appropriate action?
    1. ​Recheck and document
    2. Plan to recheck
    3. Refer to specialist for BP
    4. Order labs/review studies
    Actionable Lab Results
    ​Do providers read all labs in EHR inbox within 72 hours?​Did the provider document "abnormal labs" or appropriate diagnosis?​​Did provider take an appropriate action and document it without delay?
    • ​​30 days for microcytic anemia and elevated lead
    • 7 days for STIs, Strep throat, and abnormal TSH

The following videos are of primary care clinic leaders talking about why they participated in project RedDE!

    1. Institute of Medicine. To err is human: Building a safer health system. Washington, D.C.: National Academy Press; 1999

    2. Zwaan L, Schiff GD, Singh H. Advancing the research agenda for diagnostic error reduction. BMJ quality & safety 2013;22 Suppl 2:ii52-ii7.

    3. Graber ML. The incidence of diagnostic error in medicine. BMJ quality & safety 2013;22 Suppl 2:ii21-ii7.

    4. Singh H, Naik AD, Rao R, Petersen LA. Reducing diagnostic errors through effective communication: harnessing the power of information technology. Journal of general internal medicine 2008;23:489-94.

    5. McDonald KM, Matesic B, Contopoulos-Ioannidis DG, et al. Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Intern Med 2013;158:381-9.

    6. Singh H, Thomas EJ, Wilson L, et al. Errors of diagnosis in pediatric practice: a multisite survey. Pediatrics 2010;126:70-9.

    7. Carroll AE, Buddenbaum JL. Malpractice claims involving pediatricians: epidemiology and etiology. Pediatrics 2007;120:10-7.


Thank you to the Expert Workgroup, Quality Improvement Coaches and practices who participated in Project RedDE!

Disclaimer: This toolkit is not intended as a sole source of guidance in the management of children with elevated blood pressure, depression or abnormal laboratory results. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with these conditions. Furthermore, the information highlighted in this toolkit was selected for its value and relation to application of quality improvement to reducing diagnostic errors and does not represent an endorsement or an official opinion or position of the American Academy of Pediatrics unless noted as such

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