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Kotwal S, Howell M, Zwaan L, Wright SM. Exploring Clinical Lessons Learned by Experienced Hospitalists from Diagnostic Errors and Successes. J Gen Intern Med 2024; 39:1386-1392. [PMID: 38277023 PMCID: PMC11169201 DOI: 10.1007/s11606-024-08625-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/09/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Diagnostic errors cause significant patient harm. The clinician's ultimate goal is to achieve diagnostic excellence in order to serve patients safely. This can be accomplished by learning from both errors and successes in patient care. However, the extent to which clinicians grow and navigate diagnostic errors and successes in patient care is poorly understood. Clinically experienced hospitalists, who have cared for numerous acutely ill patients, should have great insights from their successes and mistakes to inform others striving for excellence in patient care. OBJECTIVE To identify and characterize clinical lessons learned by experienced hospitalists from diagnostic errors and successes. DESIGN A semi-structured interview guide was used to collect qualitative data from hospitalists at five independently administered hospitals in the Mid-Atlantic area from February to June 2022. PARTICIPANTS 12 academic and 12 community-based hospitalists with ≥ 5 years of clinical experience. APPROACH A constructivist qualitative approach was used and "reflexive thematic analysis" of interview transcripts was conducted to identify themes and patterns of meaning across the dataset. RESULTS Five themes were generated from the data based on clinical lessons learned by hospitalists from diagnostic errors and successes. The ideas included appreciating excellence in clinical reasoning as a core skill, connecting with patients and other members of the health care team to be able to tap into their insights, reflecting on the diagnostic process, committing to growth, and prioritizing self-care. CONCLUSIONS The study identifies key lessons learned from the errors and successes encountered in patient care by clinically experienced hospitalists. These findings may prove helpful for individuals and groups that are authentically committed to moving along the continuum from diagnostic competence towards excellence.
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Affiliation(s)
- Susrutha Kotwal
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Mason Howell
- Department of Biosciences, Rice University, Houston, TX, USA
| | - Laura Zwaan
- Erasmus Medical Center, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| | - Scott M Wright
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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2
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Ladell MM, Shafer G, Ziniel SI, Grubenhoff JA. Comparative Perspectives on Diagnostic Error Discussions Between Inpatient and Outpatient Pediatric Providers. Am J Med Qual 2023; 38:245-254. [PMID: 37678302 PMCID: PMC10484186 DOI: 10.1097/jmq.0000000000000148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Diagnostic error remains understudied and underaddressed despite causing significant morbidity and mortality. One barrier to addressing this issue remains provider discomfort. Survey studies have shown significantly more discomfort among providers in discussing diagnostic error compared with other forms of error. Whether the comfort in discussing diagnostic error differs depending on practice setting has not been previously studied. The objective of this study was to assess differences in provider willingness to discuss diagnostic error in the inpatient versus outpatient setting. A multicenter survey was sent out to 3881 providers between May and June 2018. This survey was designed to assess comfort level of discussing diagnostic error and looking at barriers to discussing diagnostic error. Forty-three percent versus 22% of inpatient versus outpatient providers (P = 0.004) were comfortable discussing short-term diagnostic error publicly. Similarly, 76% versus 60% of inpatient versus outpatient providers (P = 0.010) were comfortable discussing short-term diagnostic error privately. A higher percentage of inpatient (64%) compared with outpatient providers (46%) (P = 0.043) were comfortable discussing long-term diagnostic error privately. Forty percent versus 24% of inpatient versus outpatient providers (P = 0.018) were comfortable discussing long-term error publicly. No difference in barriers cited depending on practice setting. Inpatient providers are more comfortable discussing diagnostic error than their outpatient counterparts. More study is needed to determine the etiology of this discrepancy and to develop strategies to increase outpatient provider comfort.
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Affiliation(s)
- Meagan M. Ladell
- Department of Pediatric (Section of Emergency Medicine), Children’s Wisconsin and Medical College of Wisconsin, Milwaukee, WI
| | - Grant Shafer
- Department of Pediatrics (Section of Neonatology), Children’s Hospital of Orange County and University of California Irvine, Orange, CA
| | - Sonja I. Ziniel
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Joseph A. Grubenhoff
- Department of Pediatrics (Section of Emergency Medicine), University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
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3
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Mahajan P, Grubenhoff JA, Cranford J, Bhatt M, Chamberlain JM, Chang T, Lyttle M, Oostenbrink R, Roland D, Rudy RM, Shaw KN, Zuniga RV, Belle A, Kuppermann N, Singh H. Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network. BMJ Open Qual 2023; 12:bmjoq-2022-002062. [PMID: 36990648 PMCID: PMC10069565 DOI: 10.1136/bmjoq-2022-002062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundDiagnostic errors, reframed as missed opportunities for improving diagnosis (MOIDs), are poorly understood in the paediatric emergency department (ED) setting. We investigated the clinical experience, harm and contributing factors related to MOIDs reported by physicians working in paediatric EDs.MethodsWe developed a web-based survey in which physicians participating in the international Paediatric Emergency Research Network representing five out of six WHO regions, described examples of MOIDs involving their own or a colleague’s patients. Respondents provided case summaries and answered questions regarding harm and factors contributing to the event.ResultsOf 1594 physicians surveyed, 412 (25.8%) responded (mean age=43 years (SD=9.2), 42.0% female, mean years in practice=12 (SD=9.0)). Patient presentations involving MOIDs had common undifferentiated symptoms at initial presentation, including abdominal pain (21.1%), fever (17.2%) and vomiting (16.5%). Patients were discharged from the ED with commonly reported diagnoses, including acute gastroenteritis (16.7%), viral syndrome (10.2%) and constipation (7.0%). Most reported MOIDs (65%) were detected on ED return visits (46% within 24 hours and 76% within 72 hours). The most common reported MOID was appendicitis (11.4%), followed by brain tumour (4.4%), meningitis (4.4%) and non-accidental trauma (4.1%). More than half (59.1%) of the reported MOIDs involved the patient/parent–provider encounter (eg, misinterpreted/ignored history or an incomplete/inadequate physical examination). Types of MOIDs and contributing factors did not differ significantly between countries. More than half of patients had either moderate (48.7%) or major (10%) harm due to the MOID.ConclusionsAn international cohort of paediatric ED physicians reported several MOIDs, often in children who presented to the ED with common undifferentiated symptoms. Many of these were related to patient/parent–provider interaction factors such as suboptimal history and physical examination. Physicians’ personal experiences offer an underexplored source for investigating and mitigating diagnostic errors in the paediatric ED.
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Affiliation(s)
- Prashant Mahajan
- Emergency Medicine and Paediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph A Grubenhoff
- Paediatric Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Jim Cranford
- Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Maala Bhatt
- Paediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - James M Chamberlain
- Emergency Medicine, Children's National Medical Center, Washington, District of Columbia, USA
| | - Todd Chang
- Paediatric Emergency Medicine, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Mark Lyttle
- Paediatric Emergency Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Rianne Oostenbrink
- Paediatric Emergency Medicine, Erasmus MC-Sophia Children's Hospital, Rotterdam, UK
| | - Damian Roland
- Paediatric Emergency Medicine, University of Leicester, Leicester, UK
| | - Richard M Rudy
- Paediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kathy N Shaw
- Paediatric Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Velasco Zuniga
- Paediatric Emergency Medicine, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Apoorva Belle
- Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nathan Kuppermann
- Emergency Medicine and Paediatrics, University of California Davis, Davis, California, USA
| | - Hardeep Singh
- Medicine - Health Services Research, Baylor College of Medicine, Houston, Texas, USA
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4
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Giardina TD, Shahid U, Mushtaq U, Upadhyay DK, Marinez A, Singh H. Creating a Learning Health System for Improving Diagnostic Safety: Pragmatic Insights from US Health Care Organizations. J Gen Intern Med 2022; 37:3965-3972. [PMID: 35650467 PMCID: PMC9640494 DOI: 10.1007/s11606-022-07554-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify challenges and pragmatic strategies for improving diagnostic safety at an organizational level using concepts from learning health systems METHODS: We interviewed 32 safety leaders across the USA on how their organizations approach diagnostic safety. Participants were recruited through email and represented geographically diverse academic and non-academic settings. The interview included questions on culture of reporting and learning from diagnostic errors; data gathering and analysis activities; diagnostic training and educational activities; and engagement of clinical leadership, staff, patients, and families in diagnostic safety activities. We conducted an inductive content analysis of interview transcripts and two reviewers coded all data. RESULTS Of 32 participants, 12 reported having a specific program to address diagnostic errors. Multiple barriers to implement diagnostic safety activities emerged: serious concerns about psychological safety associated with diagnostic error; lack of infrastructure for measurement, monitoring, and improvement activities related to diagnosis; lack of leadership investment, which was often diverted to competing priorities related to publicly reported measures or other incentives; and lack of dedicated teams to work on diagnostic safety. Participants provided several strategies to overcome barriers including adapting trigger tools to identify safety events, engaging patients in diagnostic safety, and appointing dedicated diagnostic safety champions. CONCLUSIONS Several foundational building blocks related to learning health systems could inform organizational efforts to reduce diagnostic error. Promoting an organizational culture specific to diagnostic safety, using science and informatics to improve measurement and analysis, leadership incentives to build institutional capacity to address diagnostic errors, and patient engagement in diagnostic safety activities can enable progress.
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Affiliation(s)
- Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA.
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Umber Shahid
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Umair Mushtaq
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Divvy K Upadhyay
- Division of Quality, Safety and Patient Experience, Geisinger, Danville, PA, USA
| | - Abigail Marinez
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Lam D, Dominguez F, Leonard J, Wiersma A, Grubenhoff JA. Use of e-triggers to identify diagnostic errors in the paediatric ED. BMJ Qual Saf 2022; 31:735-743. [PMID: 35318272 DOI: 10.1136/bmjqs-2021-013683] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 02/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Diagnostic errors (DxEs) are an understudied source of patient harm in children rarely captured in current adverse event reporting systems. Applying electronic triggers (e-triggers) to electronic health records shows promise in identifying DxEs but has not been used in the emergency department (ED) setting. OBJECTIVES To assess the performance of an e-trigger and subsequent manual screening for identifying probable DxEs among children with unplanned admission following a prior ED visit and to compare performance to existing incident reporting systems. DESIGN/METHODS Retrospective single-centre cohort study of children ages 0-22 admitted within 14 days of a previous ED visit between 1 January 2018 and 31 December 2019. Subjects were identified by e-trigger, screened to identify cases where index visit and hospital discharge diagnoses were potentially related but pathophysiologically distinct, and then these screened-in cases were reviewed for DxE using the SaferDx Instrument. Cases of DxE identified by e-trigger were cross-referenced against existing institutional incident reporting systems. RESULTS An e-trigger identified 1915 unplanned admissions (7.7% of 24 849 total admissions) with a preceding index visit. 453 (23.7%) were screened in and underwent review using SaferDx. 92 cases were classified as likely DxEs, representing 0.4% of all hospital admissions, 4.8% among those selected by e-trigger and 20.3% among those screened in for review. Half of cases were reviewed by two reviewers using SaferDx with substantial inter-rater reliability (Cohen's κ=0.65 (95% CI 0.54 to 0.75)). Six (6.5%) cases had been reported elsewhere: two to the hospital's incident reporting system and five to the ED case review team (one reported to both). CONCLUSION An e-trigger coupled with manual screening enriched a cohort of patients at risk for DxEs. Fewer than 10% of DxEs were identified through existing surveillance systems, suggesting that they miss a large proportion of DxEs. Further study is required to identify specific clinical presentations at risk of DxEs.
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Affiliation(s)
- Daniel Lam
- Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Fidelity Dominguez
- Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jan Leonard
- Section of Pediatric Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Alexandria Wiersma
- Section of Pediatric Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Joseph A Grubenhoff
- Section of Pediatric Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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6
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Affiliation(s)
- Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine Houston, TX, USA
| | - Denise M Connor
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Gurpreet Dhaliwal
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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7
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Graham JMK, Ambroggio L, Leonard JE, Ziniel SI, Grubenhoff JA. Evaluation of feedback modalities and preferences regarding feedback on decision-making in a pediatric emergency department. Diagnosis (Berl) 2021; 9:216-224. [PMID: 34894116 DOI: 10.1515/dx-2021-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/17/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To compare pediatric emergency clinicians' attitudes toward three feedback modalities and assess clinicians' case-based feedback preferences. METHODS Electronic survey sent to pediatric emergency medicine (PEM) physicians and fellows; general pediatricians; and advanced practice providers (APPs) with nine questions exploring effectiveness and emotional impact of three feedback modalities: case-based feedback, bounce-back notifications, and biannual performance reports. Additional questions used a four-point ordinal agreement response scale and assessed clinicians' attitudes toward case review notification, case-based feedback preferences, and emotional support. Survey responses were compared by feedback modality using Pearson's chi-squared. RESULTS Of 165 eligible providers, 93 (56%) responded. Respondents agreed that case-based feedback was timely (81%), actionable (75%), prompted reflection on decision-making (92%), prompted research on current clinical practice (53%), and encouraged practice change (58%). Pediatric Emergency Care Applied Research Network (PECARN) performance reports scored the lowest on all metrics except positive feedback. No more than 40% of providers indicated that any feedback modality provided emotional support. Regarding case-based feedback, 88% of respondents desired email notification before case review and 88% desired feedback after case review. Clinicians prefer receiving feedback from someone with similar or more experience/training. Clinicians receiving feedback desire succinctness, supporting evidence, consistency, and sensitive delivery. CONCLUSIONS Case-based feedback scored highest of the three modalities and is perceived to be the most likely to improve decision-making and promote practice change. Most providers did not perceive emotional support from any feedback modality. Emotional safety warrants purposeful attention in feedback delivery. Critical components of case-based feedback include succinctness, supporting evidence, consistency, and sensitive delivery.
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Affiliation(s)
- Jessica M K Graham
- Pediatric Emergency Medicine, Children's Hospital of Colorado, Aurora, CO, USA
| | - Lilliam Ambroggio
- Pediatric Emergency Medicine, Children's Hospital of Colorado, Aurora, CO, USA.,Pediatric Hospital Medicine, Children's Hospital of Colorado, Aurora, CO, USA
| | - Jan E Leonard
- Pediatric Emergency Medicine, Children's Hospital of Colorado, Aurora, CO, USA
| | - Sonja I Ziniel
- Pediatric Hospital Medicine, Children's Hospital of Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joseph A Grubenhoff
- Pediatric Emergency Medicine, Children's Hospital of Colorado, Aurora, CO, USA
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8
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Wyner D, Wyner F, Brumbaugh D, Grubenhoff JA. A Family and Hospital's Journey and Commitment to Improving Diagnostic Safety. Pediatrics 2021; 148:183380. [PMID: 34851407 DOI: 10.1542/peds.2021-053091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | - David Brumbaugh
- Children's Hospital Colorado, Aurora, Colorado.,Sections of Gastroenterology, Hepatology and Nutrition
| | - Joseph A Grubenhoff
- Children's Hospital Colorado, Aurora, Colorado.,Emergency Medicine, Department of Pediatrics, School of Medicine, University of Colorado
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9
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Michelson KA, Williams DN, Dart AH, Mahajan P, Aaronson EL, Bachur RG, Finkelstein JA. Development of a rubric for assessing delayed diagnosis of appendicitis, diabetic ketoacidosis and sepsis. Diagnosis (Berl) 2021; 8:219-225. [PMID: 32589599 PMCID: PMC7759568 DOI: 10.1515/dx-2020-0035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/14/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Using case review to determine whether a patient experienced a delayed diagnosis is challenging. Measurement would be more accurate if case reviewers had access to multi-expert consensus on grading the likelihood of delayed diagnosis. Our objective was to use expert consensus to create a guide for objectively grading the likelihood of delayed diagnosis of appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. METHODS Case vignettes were constructed for each condition. In each vignette, a patient has the condition and had a previous emergency department (ED) visit within 7 days. Condition-specific multi-specialty expert Delphi panels reviewed the case vignettes and graded the likelihood of a delayed diagnosis on a five-point scale. Delayed diagnosis was defined as the condition being present during the previous ED visit. Consensus was defined as ≥75% agreement. In each Delphi round, panelists were given the scores from the previous round and asked to rescore. A case scoring guide was created from the consensus scores. RESULTS Eighteen expert panelists participated. Consensus was achieved within three Delphi rounds for all appendicitis and sepsis vignettes. We reached consensus on 23/30 (77%) DKA vignettes. A case review guide was created from the consensus scores. CONCLUSIONS Multi-specialty expert reviewers can agree on the likelihood of a delayed diagnosis for cases of appendicitis and sepsis, and for most cases of DKA. We created a guide that can be used by researchers and quality improvement specialists to allow for objective case review to determine when delayed diagnoses have occurred for appendicitis, DKA, and sepsis.
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Affiliation(s)
| | - David N. Williams
- Division of Orthopedic Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Arianna H. Dart
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Emily L. Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Richard G. Bachur
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
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When Measuring Is More Important than Measurement: The Importance of Measuring Diagnostic Errors in Health Care. J Pediatr 2021; 232:14-16. [PMID: 33388301 DOI: 10.1016/j.jpeds.2020.12.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 12/30/2020] [Indexed: 11/23/2022]
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Abstract
ABSTRACT Fundamental to the practice of pediatric emergency medicine is making timely and accurate diagnoses. However, studies have shown errors in this process are common. A number of factors in the emergency department environment as well as identifiable errant patterns of thinking can contribute to such challenges. Cognitive psychologists have described 2 types of thinking: system 1 (fast) relies primarily on intuition and pattern recognition, whereas system 2 (slow) is more deliberative and analytical. Reviewing how these 2 styles of thinking are applied in clinical practice provides a framework for understanding specific cognitive errors. This article uses illustrative examples to introduce many of these common errors, providing context for how and why they occur. In addition, a practical approach to reducing the risk of such errors is offered.
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12
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Searns JB, Williams MC, MacBrayne CE, Wirtz AL, Leonard JE, Boguniewicz J, Parker SK, Grubenhoff JA. Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. Diagnosis (Berl) 2020; 8:347-352. [PMID: 33112779 DOI: 10.1515/dx-2020-0032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 09/17/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Few studies describe the impact of antimicrobial stewardship programs (ASPs) on recognizing and preventing diagnostic errors. Handshake stewardship (HS-ASP) is a novel ASP model that prospectively reviews hospital-wide antimicrobial usage with recommendations made in person to treatment teams. The purpose of this study was to determine if HS-ASP could identify and intervene on potential diagnostic errors for children hospitalized at a quaternary care children's hospital. METHODS Previously self-identified "Great Catch" (GC) interventions by the Children's Hospital Colorado HS-ASP team from 10/2014 through 5/2018 were retrospectively reviewed. Each GC was categorized based on the types of recommendations from HS-ASP, including if any diagnostic recommendations were made to the treatment team. Each GC was independently scored using the "Safer Dx Instrument" to determine presence of diagnostic error based on a previously determined cut-off score of ≤1.50. Interrater reliability for the instrument was measured using a randomized subset of one third of GCs. RESULTS During the study period, there were 162 GC interventions. Of these, 65 (40%) included diagnostic recommendations by HS-ASP and 19 (12%) had a Safer Dx Score of ≤1.50, (Κ=0.44; moderate agreement). Of those GCs associated with diagnostic errors, the HS-ASP team made a diagnostic recommendation to the primary treatment team 95% of the time. CONCLUSIONS Handshake stewardship has the potential to identify and intervene on diagnostic errors for hospitalized children.
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Affiliation(s)
- Justin B Searns
- Divisions of Hospital Medicine & Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, 13123 E 16th Ave, B302, Aurora, CO 80045, USA
| | - Manon C Williams
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Christine E MacBrayne
- Department of Pharmacy, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Ann L Wirtz
- Department of Pharmacy, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Jan E Leonard
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Juri Boguniewicz
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Sarah K Parker
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Joseph A Grubenhoff
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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13
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Meyer AND, Upadhyay DK, Collins CA, Fitzpatrick MH, Kobylinski M, Bansal AB, Torretti D, Singh H. A Program to Provide Clinicians with Feedback on Their Diagnostic Performance in a Learning Health System. Jt Comm J Qual Patient Saf 2020; 47:120-126. [PMID: 32980255 DOI: 10.1016/j.jcjq.2020.08.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 02/07/2023]
Abstract
PROBLEM Reducing diagnostic errors requires improving both systems and individual clinical reasoning. One strategy to achieve diagnostic excellence is learning from feedback. However, clinicians remain uncomfortable receiving feedback on their diagnostic performance. Thus, a team of researchers and clinical leaders aimed to develop and implement a diagnostic performance feedback program for learning that mitigates potential clinician discomfort. APPROACH The program was developed as part of a larger project to create a learning health system around diagnostic safety at Geisinger, a large, integrated health care system in rural Pennsylvania. Steps included identifying potential missed opportunities in diagnosis (MODs) from various sources (for example, risk management, clinician reports, patient complaints); confirming MODs through chart review; and having trained facilitators provide feedback to clinicians about MODs as learning opportunities. The team developed a guide for facilitators to conduct effective diagnostic feedback sessions and surveyed facilitators and recipients about their experiences and perceptions of the feedback sessions. OUTCOMES 28 feedback sessions occurred from January 2019 to June 2020, involving MODs from emergency medicine, primary care, and hospital medicine. Most facilitators (90.6% [29/32]) reported that recipients were receptive to learning and discussing MODs. Most recipients reported that conversations were constructive and nonpunitive (83.3% [25/30]) and allowed them to take concrete steps toward improving diagnosis (76.7% [23/30]). Both groups believed discussions would improve future diagnostic safety (93.8% [30/32] and 70.0% [21/30], respectively). KEY INSIGHTS AND NEXT STEPS An institutional program was developed and implemented to deliver diagnostic performance feedback. Such a program may facilitate learning and improvement to reduce MODs. Future efforts should assess long-term effects on diagnostic performance and patient outcomes.
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