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The Joint Commission Issues Sentinel Event Alert on Diagnostic Overshadowing

Addresses How Diagnostic Overshadowing Impacts Groups Experiencing Health Disparities Wednesday, June 22, 2022

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Maureen Lyons
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(OAKBROOK TERRACE, Illinois, June 22, 2022) – The Joint Commission today issued a new Sentinel Event Alert, “Diagnostic overshadowing among groups experiencing health disparities.” The alert addresses why it is important to address diagnostic overshadowing – the attribution of symptoms to an existing diagnosis rather than a potential co-morbid condition – and provides recommended safety actions.

Evidence suggests that diagnostic overshadowing exists within the interactions of clinicians with patients of all ages who have physical disabilities or previous diagnoses such as, but not limited to, autism, mobility disabilities and neurological deficits, as well as patients with conditions or characteristics such as, but not limited to, LGBTQ identifications, history of substance abuse, low health literacy and obesity.

“Diagnostic overshadowing is a serious safety and quality concern as an initial misdiagnosis can have a significant impact on quality of life, including the physical and psychological wellness of patients,” says Ana Pujols McKee, MD, executive vice president, chief medical officer, and chief diversity, equity and inclusion officer, The Joint Commission. “I urge my physician colleagues to recognize that diagnostic overshadowing stems from cognitive bias and work to reduce this through training and education programs. Such bias can have a detrimental effect on future patient workups and how handoffs to other providers are framed.”

Actions suggested by The Joint Commission in the alert include:

  1. Create an awareness of diagnostic overshadowing during clinical peer and quality assurance reviews and by addressing it in training and education programs. 
  2. Use listening and interviewing techniques designed to gain better patient engagement and shared decision making. 
  3. Collect and aggregate data about pre-existing conditions and disabilities and create electronic health record (EHR) prompts for clinicians. 
  4. Use an intersectional framework when assessing patients in groups prone to diagnostic overshadowing to overcome cognitive biases and look beyond previous diagnoses. 
  5. Review your organization’s ADA compliance using the added perspective of diagnostic overshadowing to ensure that it meets the needs of patients with physical disabilities.

Additionally, the alert provides a list of related Joint Commission requirements that address disparities and disability issues.

The Sentinel Event Alert is available on The Joint Commission website. It may be reproduced if credited to The Joint Commission.


About The Joint Commission

Founded in 1951, The Joint Commission seeks to continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission accredits and certifies more than 22,000 healthcare organizations and programs in the United States. An independent, nonprofit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in healthcare. Learn more about The Joint Commission at