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Gleason KT, Dukhanin V, Peterson SK, Gonzalez N, Austin JM, McDonald KM. Development and Psychometric Analysis of a Patient-Reported Measure of Diagnostic Excellence for Emergency and Urgent Care Settings. J Patient Saf 2024; 20:498-504. [PMID: 39194332 DOI: 10.1097/pts.0000000000001271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
BACKGROUND Emergency and urgent care settings face challenges with routinely obtaining performance feedback related to diagnostic care. Patients and their care partners provide an important perspective on the diagnostic process and outcome of care in these settings. We sought to develop and test psychometric properties of Patient-Report to IMprove Diagnostic Excellence in Emergency Department settings (PRIME-ED), a measure of patient-reported diagnostic excellence in these care settings. METHODS We developed PRIME-ED based on literature review, expert feedback, and cognitive testing. To assess psychometric properties, we surveyed AmeriSpeak, a probability-based panel that provides sample coverage of approximately 97% of the U.S. household population, in February 2022 to adult patients, or their care partners, who had presented to an emergency department or urgent care facility within the last 30 days. Respondents rated their agreement on a 5-point Likert scale with each of 17 statements across multiple domains of patient-reported diagnostic excellence. Demographics, visit characteristics, and a subset of the Emergency Department Consumer Assessment of Healthcare Providers & Systems were also collected. We conducted psychometric testing for reliability and validity. RESULTS Over a thousand (n = 1116) national panelists completed the PRIME-ED survey, of which 58.7% were patients and 40.9% were care partners; 49.6% received care at an emergency department and 49.9% at an urgent care facility. Responses had high internal consistency within 3 patient-reported diagnostic excellence domain groupings: diagnostic process (Cronbach's alpha 0.94), accuracy of diagnosis (0.93), and communication of diagnosis (0.94). Domain groupings were significantly correlated with concurrent Emergency Department Consumer Assessment of Healthcare Providers & Systems items. Factor analyses substantiated 3 domain groupings. CONCLUSIONS PRIME-ED has potential as a tool for capturing patient-reported diagnostic excellence in emergency and urgent care.
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Affiliation(s)
- Kelly T Gleason
- From the Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Vadim Dukhanin
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Susan K Peterson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - J M Austin
- Armstrong Institute for Patient Safety and Quality and Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Brady PW, Ruddy RM, Ehrhardt J, Corathers SD, Kirkendall ES, Walsh KE. Assessing the Revised Safer Dx Instrument ® in the understanding of ambulatory system design changes for type 1 diabetes and autism spectrum disorder in pediatrics. Diagnosis (Berl) 2024; 11:266-272. [PMID: 38517065 PMCID: PMC11306753 DOI: 10.1515/dx-2023-0166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/27/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVES We sought within an ambulatory safety study to understand if the Revised Safer Dx instrument may be helpful in identification of diagnostic missed opportunities in care of children with type 1 diabetes (T1D) and autism spectrum disorder (ASD). METHODS We reviewed two months of emergency department (ED) encounters for all patients at our tertiary care site with T1D and a sample of such encounters for patients with ASD over a 15-month period, and their pre-visit communication methods to better understand opportunities to improve diagnosis. We applied the Revised Safer Dx instrument to each diagnostic journey. We chose potentially preventable ED visits for hyperglycemia, diabetic ketoacidosis, and behavioral crises, and reviewed electronic health record data over the prior three months related to the illness that resulted in the ED visit. RESULTS We identified 63 T1D and 27 ASD ED visits. Using the Revised Safer Dx instrument, we did not identify any potentially missed opportunities to improve diagnosis in T1D. We found two potential missed opportunities (Safer Dx overall score of 5) in ASD, related to potential for ambulatory medical management to be improved. Over this period, 40 % of T1D and 52 % of ASD patients used communication prior to the ED visit. CONCLUSIONS Using the Revised Safer Dx instrument, we uncommonly identified missed opportunities to improve diagnosis in patients who presented to the ED with potentially preventable complications of their chronic diseases. Future researchers should consider prospectively collected data as well as development or adaptation of tools like the Safer Dx.
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Affiliation(s)
- Patrick W. Brady
- Division of Hospital Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Richard M. Ruddy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Emergency Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Jennifer Ehrhardt
- Division of Development and Behavioral Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Sarah D. Corathers
- Division of Hospital Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, OH, USA
- Division of Endocrinology, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Eric S. Kirkendall
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kathleen E. Walsh
- Department of General Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Boston Children’s Hospital,, Boston, MA, USA
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Miyagami T, Watari T, Nishizaki Y, Sekine M, Shigetomi K, Miwa M, Chopra V, Naito T. Survey on nurse-physician communication gaps focusing on diagnostic concerns and reasons for silence. Sci Rep 2024; 14:17362. [PMID: 39075186 PMCID: PMC11286969 DOI: 10.1038/s41598-024-68520-6] [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] [Received: 02/26/2024] [Accepted: 07/24/2024] [Indexed: 07/31/2024] Open
Abstract
Diagnosis improvement requires physician-nurse collaboration. This study explored nurses' concerns regarding physicians' diagnoses and how they were communicated to physicians. This cross-sectional study, employing a web-based questionnaire, included nurses registered on Japan's largest online media site from June 26, 2023, to July 31, 2023. The survey inquired whether participants felt concerned about a physician's diagnosis within a month, if they communicated their concerns once they arose, and, if not, their reasons. The reasons for not being investigated were also examined. The nurses' frequency of feeling concerned about a physician's diagnosis and the barriers to communicating these concerns to the physician were evaluated. Overall, 430 nurses answered the survey (female, 349 [81.2%]; median age, 45 [35-51] years; median years of experience, 19 [12-25]). Of the nurses, 61.2% experienced concerns about a physician's diagnosis within the past month; 52.5% felt concerned but did not communicate this to the physician. The most common reasons for not communicating included concern about the physician's pride, being ignored when communicating, and the nurse not believing that a diagnosis should be made. Our results highlight the need to foster psychologically safe workplaces for nurses and create educational programs encouraging nurse involvement in diagnosis.
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Affiliation(s)
- Taiju Miyagami
- Department of General Medicine, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan.
| | - Takashi Watari
- General Medicine Center, Shimane University Hospital, Izumo, Japan
| | - Yuji Nishizaki
- Department of General Medicine, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan
- Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan
| | - Miwa Sekine
- Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan
- Medical Technology Innovation Center, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kyoko Shigetomi
- Department of Cardiovascular Surgery, Juntendo University Hospital, Tokyo, Japan
| | - Mamoru Miwa
- Nikkei Business Publications, Inc, Tokyo, Japan
| | - Vineet Chopra
- Department of Medicine, Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Toshio Naito
- Department of General Medicine, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan
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4
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Rodino KG, Luethy PM, Abbott AN, Bender JM, Eberly AR, Gitman M, Leber A, Dien Bard J. Defining the value of medical microbiology consultation. J Clin Microbiol 2024:e0035924. [PMID: 38904385 DOI: 10.1128/jcm.00359-24] [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: 02/27/2024] [Accepted: 05/30/2024] [Indexed: 06/22/2024] Open
Abstract
Medical microbiologists, defined as doctoral-level laboratory directors with subspecialty training in medical microbiology, lead the clinical laboratory operations through activities such as clinical consultations, oversight of diagnostic testing menu, institutional leadership, education, and scholastic activities. However, unlike their clinical colleagues, medical microbiologists are largely unable to bill for clinical consultations performed within the hospital and, therefore, unable to generate relative value units or a similar quantifiable metric. As hospital budgets tighten and justification of staffing becomes a necessity, this may present a challenge to the medical microbiologist attempting to prove their value to the organization. To aid in providing tangible data, the Personnel Standards and Workforce subcommittee of the American Society for Microbiology conducted a multi-center study across seven medical centers to document clinical consultations and their impact. Consults were generated equally from internal (laboratory-based) and external (hospital-based) parties, with the majority directly impacting patient management. Near universal acceptance of the medical microbiologist's recommendation highlights the worth derived from their expertise. External consults required more time commitment from the medical microbiologist than internal consults, although both presented ample opportunity for secondary value, including impact through stewardship, education, clinical guidance, and cost reduction. This study is a description of the content and impact of consultations that underscore the importance of the medical microbiologist as a key member of the healthcare team. IMPORTANCE Medical microbiologists are invaluable to the clinical microbiology laboratory and the healthcare system as a whole. However, as medical microbiologists do not regularly generate relative value units, capturing and quantifying the value provided is challenging. As hospital budgets tighten, justification of staffing becomes a necessity. To aid in providing tangible data, the Personnel Standards and Workforce subcommittee of the American Society for Microbiology conducted a multi-center study across seven medical centers to document clinical consultations and their impact. To our knowledge, this is the first study to provide detailed evaluation of the consultative value provided by medical microbiologists.
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Affiliation(s)
- Kyle G Rodino
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul M Luethy
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - April N Abbott
- Department of Laboratory Medicine, Deaconess Health System, Evansville, Indiana, USA
| | - Jeffrey M Bender
- Department of Pediatrics, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Allison R Eberly
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Melissa Gitman
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy Leber
- Department of Laboratory Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Jennifer Dien Bard
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Kämmer JE, Boos M, Seelandt JC. Editorial: Promoting teamwork in healthcare. Front Psychol 2024; 15:1422543. [PMID: 38947908 PMCID: PMC11212510 DOI: 10.3389/fpsyg.2024.1422543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 05/28/2024] [Indexed: 07/02/2024] Open
Affiliation(s)
- Juliane E. Kämmer
- Department of Emergency Medicine, University of Bern, Bern, Switzerland
| | - Margarete Boos
- Institute for Psychology, Georg August University Göttingen, Göttingen, Germany
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Parsons AS, Wijesekera TP, Olson APJ, Torre D, Durning SJ, Daniel M. Beyond thinking fast and slow: Implications of a transtheoretical model of clinical reasoning and error on teaching, assessment, and research. MEDICAL TEACHER 2024:1-12. [PMID: 38835283 DOI: 10.1080/0142159x.2024.2359963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 05/22/2024] [Indexed: 06/06/2024]
Abstract
From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.
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Affiliation(s)
- Andrew S Parsons
- Medicine and Public Health, University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Andrew P J Olson
- Medicine and Pediatrics, Medical Education Outcomes Center, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Dario Torre
- Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Steven J Durning
- Medicine and Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Michelle Daniel
- Emergency Medicine, University of California San Diego School of Medicine San Diego, CA, USA
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Penner JC, Schuwirth L, Durning SJ. From Noise to Music: Reframing the Role of Context in Clinical Reasoning. J Gen Intern Med 2024; 39:851-857. [PMID: 38243110 PMCID: PMC11043232 DOI: 10.1007/s11606-024-08612-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 01/05/2024] [Indexed: 01/21/2024]
Affiliation(s)
- John C Penner
- Department of Medicine, University of California, San Francisco, CA, USA.
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Lambert Schuwirth
- Prideaux Discipline of Clinical Education, Flinders University, Adelaide, SA, Australia
| | - Steven J Durning
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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8
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Liu SK, Bourgeois F, Dong J, Harcourt K, Lowe E, Salmi L, Thomas EJ, Riblet N, Bell SK. What's going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process. Diagnosis (Berl) 2024; 11:63-72. [PMID: 38114888 PMCID: PMC10875277 DOI: 10.1515/dx-2023-0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/18/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVES Accurate and timely diagnosis relies on close collaboration between patients/families and clinicians. Just as patients have unique insights into diagnostic breakdowns, positive patient feedback may also generate broader perspectives on what constitutes a "good" diagnostic process (DxP). METHODS We evaluated patient/family feedback on "what's going well" as part of an online pre-visit survey designed to engage patients/families in the DxP. Patients/families living with chronic conditions with visits in three urban pediatric subspecialty clinics (site 1) and one rural adult primary care clinic (site 2) were invited to complete the survey between December 2020 and March 2022. We adapted the Healthcare Complaints Analysis Tool (HCAT) to conduct a qualitative analysis on a subset of patient/family responses with ≥20 words. RESULTS In total, 7,075 surveys were completed before 18,129 visits (39 %) at site 1, and 460 surveys were completed prior to 706 (65 %) visits at site 2. Of all participants, 1,578 volunteered positive feedback, ranging from 1-79 words. Qualitative analysis of 272 comments with ≥20 words described: Relationships (60 %), Clinical Care (36 %), and Environment (4 %). Compared to primary care, subspecialty comments showed the same overall rankings. Within Relationships, patients/families most commonly noted: thorough and competent attention (46 %), clear communication and listening (41 %) and emotional support and human connection (39 %). Within Clinical Care, patients highlighted: timeliness (31 %), effective clinical management (30 %), and coordination of care (25 %). CONCLUSIONS Patients/families valued relationships with clinicians above all else in the DxP, emphasizing the importance of supporting clinicians to nurture effective relationships and relationship-centered care in the DxP.
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Affiliation(s)
- Stephen K. Liu
- White River Junction VA Medical Center, White River Junction, VT, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Fabienne Bourgeois
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Joe Dong
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kendall Harcourt
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Elizabeth Lowe
- Patient and Family Advisory Council, Department of Social Work, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Liz Salmi
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eric J. Thomas
- Department of Medicine, University of Texas McGovern Medical School, Houston, TX, USA
- Center for Healthcare Quality and Safety, Memorial Hermann Texas Medical Center, Houston, TX, USA
| | - Natalie Riblet
- White River Junction VA Medical Center, White River Junction, VT, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Sigall K. Bell
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Ali KJ, Goeschel CA, DeLia DM, Blackall LM, Singh H. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare. Diagnosis (Berl) 2024; 11:17-24. [PMID: 37795579 DOI: 10.1515/dx-2023-0042] [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] [Received: 04/09/2023] [Accepted: 08/26/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVES No framework currently exists to guide how payers and providers can collaboratively develop and implement incentives to improve diagnostic safety. We conducted a literature review and interviews with subject matter experts to develop a multi-component 'Payer Relationships for Improving Diagnoses (PRIDx)' framework, that could be used to engage payers in diagnostic safety efforts. CONTENT The PRIDx framework, 1) conceptualizes diagnostic safety links to care provision, 2) illustrates ways to promote payer and provider engagement in the design and adoption of accountability mechanisms, and 3) explicates the use of data analytics. Certain approaches suggested by PRIDx were refined by subject matter expert interviewee perspectives. SUMMARY The PRIDx framework can catalyze public and private payers to take specific actions to improve diagnostic safety. OUTLOOK Implementation of the PRIDx framework requires new types of partnerships, including external support from public and private payer organizations, and requires creation of strong provider incentives without undermining providers' sense of professionalism and autonomy. PRIDx could help facilitate collaborative payer-provider approaches to improve diagnostic safety and generate research concepts, policy ideas, and potential innovations for engaging payers in diagnostic safety improvement activities.
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Affiliation(s)
- Kisha J Ali
- MedStar Institute for Quality and Safety, Columbia, MD, USA
| | - Christine A Goeschel
- MedStar Institute for Quality and Safety, Columbia, MD, USA
- Georgetown University School of Medicine, Washington, DC, USA
| | - Derek M DeLia
- Rutgers University, Bloustein School of Planning and Public Policy, New Brunswick, NJ, USA
| | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
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Hansen NL, Precht H, Larsen P, Noehr-Jensen L. Interprofessional diagnostic management teams: a scoping review protocol. Syst Rev 2023; 12:223. [PMID: 37993968 PMCID: PMC10664282 DOI: 10.1186/s13643-023-02391-2] [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: 01/18/2023] [Accepted: 11/16/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Diagnostic errors are a major problem in healthcare. In 2015, the report "Improving Diagnosis in Health Care" by the National Academies of Sciences, Engineering, and Medicine (NASEM) stated that it is likely that most people will experience at least one diagnostic error in their lifetime. The report suggests implementing diagnostic management teams, including patients and their relatives, diagnosticians, and healthcare professionals who support the diagnostic process, to limit diagnostic error and improve patient safety. Implementing interprofessional diagnostic management teams (IDMT), however, is not an easy task due to the complexity of the diagnostic processes and the traditional organization of healthcare with divided departments and healthcare professional who operate in different geographic locations. As this topic is still emerging, a scoping review is ideal to determine the scope of the body of literature on IDMT, indicate the volume of literature and studies available and identify any gaps in knowledge. In a long-term perspective, this scoping review will contribute to prevent diagnostic errors and improve patient safety, for adults and children with physical health issues. METHODS We will conduct this scoping review in accordance with the JBI methodology and report it based on the PRISMA-ScR. We will systematically search six databases (EMBASE, PubMed, CINAHL, Academic Search Premier, SCOPUS and Web of Science) for papers published between 1985 and 2023 that describe the use of interprofessional diagnostic management teams. The participants included will be adults and children seeking diagnostic care for physical health issues. The concept studied will be interprofessional diagnostic management teams, and the context will be the diagnostic process in the healthcare system. Studies examining the diagnostic process in psychiatry, odontology or complementary medicine will be excluded. Data extraction, including key study characteristics and findings, will be done by two reviewers independently. Any disagreement will be resolved by discussion and eventually by including the two remainder reviewers. DISCUSSION To our knowledge, this will be the first scoping review regarding IDMT and the derived effects on diagnostic safety and can therefore be a very important contribution to improve patient safety significantly during the diagnostic process. PROTOCOL REGISTRATION The project is registered at Open Science Framework (OSF) with ID: osf.io/kv2n6.
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Affiliation(s)
- Nicoline Lykke Hansen
- Biomedical Laboratory Science, UCL University College, Niels Bohrs Allé 1, 5230, Odense S, Denmark
- Health Sciences Research Centre, UCL University College, Niels Bohrs Allé 1, 5230, Odense S, Denmark
| | - Helle Precht
- Health Sciences Research Centre, UCL University College, Niels Bohrs Allé 1, 5230, Odense S, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Radiology, Kolding, Lillebaelt Hospital, University Hospitals of Southern Denmark, Odense, Denmark
| | - Palle Larsen
- Health Sciences Research Centre, UCL University College, Niels Bohrs Allé 1, 5230, Odense S, Denmark
| | - Lene Noehr-Jensen
- Biomedical Laboratory Science, UCL University College, Niels Bohrs Allé 1, 5230, Odense S, Denmark.
- Health Sciences Research Centre, UCL University College, Niels Bohrs Allé 1, 5230, Odense S, Denmark.
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11
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Cifra CL, Custer JW, Smith CM, Smith KA, Bagdure DN, Bloxham J, Goldhar E, Gorga SM, Hoppe EM, Miller CD, Pizzo M, Ramesh S, Riffe J, Robb K, Simone SL, Stoll HD, Tumulty JA, Wall SE, Wolfe KK, Wendt L, Eyck PT, Landrigan CP, Dawson JD, Reisinger HS, Singh H, Herwaldt LA. Prevalence and Characteristics of Diagnostic Error in Pediatric Critical Care: A Multicenter Study. Crit Care Med 2023; 51:1492-1501. [PMID: 37246919 PMCID: PMC10615661 DOI: 10.1097/ccm.0000000000005942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES Effective interventions to prevent diagnostic error among critically ill children should be informed by diagnostic error prevalence and etiologies. We aimed to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU. DESIGN Multicenter retrospective cohort study using structured medical record review by trained clinicians using the Revised Safer Dx instrument to identify diagnostic error (defined as missed opportunities in diagnosis). Cases with potential errors were further reviewed by four pediatric intensivists who made final consensus determinations of diagnostic error occurrence. Demographic, clinical, clinician, and encounter data were also collected. SETTING Four academic tertiary-referral PICUs. PATIENTS Eight hundred eighty-two randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 882 patient admissions, 13 (1.5%) had a diagnostic error up to 7 days after PICU admission. Infections (46%) and respiratory conditions (23%) were the most common missed diagnoses. One diagnostic error caused harm with a prolonged hospital stay. Common missed diagnostic opportunities included failure to consider the diagnosis despite a suggestive history (69%) and failure to broaden diagnostic testing (69%). Unadjusted analysis identified more diagnostic errors in patients with atypical presentations (23.1% vs 3.6%, p = 0.011), neurologic chief complaints (46.2% vs 18.8%, p = 0.024), admitting intensivists greater than or equal to 45 years old (92.3% vs 65.1%, p = 0.042), admitting intensivists with more service weeks/year (mean 12.8 vs 10.9 wk, p = 0.031), and diagnostic uncertainty on admission (77% vs 25.1%, p < 0.001). Generalized linear mixed models determined that atypical presentation (odds ratio [OR] 4.58; 95% CI, 0.94-17.1) and diagnostic uncertainty on admission (OR 9.67; 95% CI, 2.86-44.0) were significantly associated with diagnostic error. CONCLUSIONS Among critically ill children, 1.5% had a diagnostic error up to 7 days after PICU admission. Diagnostic errors were associated with atypical presentations and diagnostic uncertainty on admission, suggesting possible targets for intervention.
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Affiliation(s)
- Christina L. Cifra
- Division of Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Division of Medical Critical Care, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason W. Custer
- Division of Critical Care, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Craig M. Smith
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kristen A. Smith
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Dayanand N. Bagdure
- Department of Pediatrics, Louisiana State University Health Shreveport School of Medicine, Shreveport, Louisiana
| | - Jodi Bloxham
- University of Iowa College of Nursing, Iowa City, Iowa
| | - Emily Goldhar
- Pediatric Intensive Care Unit, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Stephen M. Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Elizabeth M. Hoppe
- Pediatric Intensive Care Unit, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Christina D. Miller
- Department of Pediatrics, Section of Critical Care, University of Colorado School of Medicine, Aurora, Colorado
| | - Max Pizzo
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Sonali Ramesh
- Department of Pediatrics, BronxCare Health System, New York, New York
| | - Joseph Riffe
- Department of Pediatrics, Family First Health, York, Pennsylvania
| | - Katharine Robb
- Division of Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Shari L. Simone
- University of Maryland School of Nursing, Baltimore, Maryland
| | | | - Jamie Ann Tumulty
- Pediatric Intensive Care Unit, University of Maryland Children’s Hospital, Baltimore, Maryland
| | - Stephanie E. Wall
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Katie K. Wolfe
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Linder Wendt
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa
| | - Patrick Ten Eyck
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey D. Dawson
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa
| | - Heather Schacht Reisinger
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Loreen A. Herwaldt
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
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12
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Choi JJ, Rosen MA, Shapiro MF, Safford MM. Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process. Diagnosis (Berl) 2023; 10:363-374. [PMID: 37561698 DOI: 10.1515/dx-2023-0065] [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] [Received: 06/08/2023] [Accepted: 07/31/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVES Achieving diagnostic excellence on medical wards requires teamwork and effective team dynamics. However, the study of ward team dynamics in teaching hospitals is relatively underdeveloped. We aim to enhance understanding of how ward team members interact in the diagnostic process and of the underlying behavioral, psychological, and cognitive mechanisms driving team interactions. METHODS We used mixed-methods to develop and refine a conceptual model of how ward team dynamics in an academic medical center influence the diagnostic process. First, we systematically searched existing literature for conceptual models and empirical studies of team dynamics. Then, we conducted field observations with thematic analysis to refine our model. RESULTS We present a conceptual model of how medical ward team dynamics influence the diagnostic process, which serves as a roadmap for future research and interventions in this area. We identified three underexplored areas of team dynamics that are relevant to diagnostic excellence and that merit future investigation (1): ward team structures (e.g., team roles, responsibilities) (2); contextual factors (e.g., time constraints, location of team members, culture, diversity); and (3) emergent states (shared mental models, psychological safety, team trust, and team emotions). CONCLUSIONS Optimizing the diagnostic process to achieve diagnostic excellence is likely to depend on addressing all of the potential barriers and facilitators to ward team dynamics presented in our model.
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Affiliation(s)
- Justin J Choi
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Michael A Rosen
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Institute for Clinical and Translational Research, and JHSOM Simulation Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Martin F Shapiro
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Monika M Safford
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
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13
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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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14
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Alanazi A, Almutib A, Aldosari B. Physicians' Perspectives on a Multi-Dimensional Model for the Roles of Electronic Health Records in Approaching a Proper Differential Diagnosis. J Pers Med 2023; 13:jpm13040680. [PMID: 37109066 PMCID: PMC10146177 DOI: 10.3390/jpm13040680] [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: 03/20/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Many healthcare organizations have adopted Electronic Health Records (EHRs) to improve the quality of care and help physicians make proper clinical decisions. The vital roles of EHRs can support the accuracy of diagnosis, suggest, and rationalize the provided care to patients. This study aims to understand the roles of EHRs in approaching proper differential diagnosis and optimizing patient safety. This study utilized a cross-sectional survey-based descriptive research design to assess physicians' perceptions of the roles of EHRs on diagnosis quality and safety. Physicians working in tertiary hospitals in Saudi Arabia were surveyed. Three hundred and fifty-one participants were included in the study, of which 61% were male. The main participants were family/general practice (22%), medicine, general (14%), and OB/GYN (12%). Overall, 66% of the participants ranked themselves as IT competent, most of the participants underwent IT self-guided learning, and 65% of the participants always used the system. The results generally reveal positive physicians' perceptions toward the roles of the EHR system on diagnosis quality and safety. There was a statistically significant relationship between user characteristics and the roles of the EHR by enhancing access to care, patient-physician encounter, clinical reasoning, diagnostic testing and consultation, follow-up, and diagnostic safety functionality. The study participants demonstrate positive perceptions of physicians toward the roles of the EHR system in approaching differential diagnosis. Yet, areas of improvement in the design and using EHRs are emphasized.
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Affiliation(s)
- Abdullah Alanazi
- Health Informatics Department, King Saud Ibn Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 14611, Saudi Arabia
| | - Amal Almutib
- Health Informatics Department, King Saud Ibn Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 14611, Saudi Arabia
| | - Bakheet Aldosari
- Health Informatics Department, King Saud Ibn Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 14611, Saudi Arabia
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15
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Pisciotta W, Arina P, Hofmaenner D, Singer M. Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias. Anaesthesia 2023; 78:501-509. [PMID: 36633483 DOI: 10.1111/anae.15897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 01/13/2023]
Abstract
Dealing with an uncertain or missed diagnosis is commonplace in the intensive care unit setting. Affected patients are subject to a potential decrease in quality of care and a greater risk of a poor outcome. The diagnostic process is a complex task that starts with information gathering, followed by integration and interpretation of data, hypothesis generation and, finally, confirmation of a (hopefully correct) diagnosis. This may be particularly challenging in the patient who is critically ill where a good history may not be forthcoming and/or clinical, laboratory and imaging features are non-specific. The aim of this narrative review is to analyse and describe common causes of diagnostic error in the intensive care unit, highlighting the multiple types of cognitive bias, and to suggest a diagnostic framework. To inform this review, we performed a literature search to identify relevant articles, particularly those pertinent to unclear diagnoses in patients who are critically ill. Clinicians should be cognisant as to how they formulate diagnoses and utilise debiasing strategies. Multidisciplinary teamwork and more time spent with the patient, supported by effective and efficient use of electronic healthcare records and decision support resources, is likely to improve the quality of the diagnostic process, patient care and outcomes.
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Affiliation(s)
- W Pisciotta
- Bloomsbury Institute of Intensive Care Medicine, University College London, UK.,IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - P Arina
- Bloomsbury Institute of Intensive Care Medicine, University College London, UK
| | - D Hofmaenner
- Bloomsbury Institute of Intensive Care Medicine, University College London, UK.,Institute of Intensive Care Medicine, University Hospital Zurich, Switzerland
| | - M Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, UK
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16
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Twarowski B, Herbet M. Inflammatory Processes in Alzheimer's Disease-Pathomechanism, Diagnosis and Treatment: A Review. Int J Mol Sci 2023; 24:6518. [PMID: 37047492 PMCID: PMC10095343 DOI: 10.3390/ijms24076518] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Alzheimer's disease is one of the most commonly diagnosed cases of senile dementia in the world. It is an incurable process, most often leading to death. This disease is multifactorial, and one factor of this is inflammation. Numerous mediators secreted by inflammatory cells can cause neuronal degeneration. Neuritis may coexist with other mechanisms of Alzheimer's disease, contributing to disease progression, and may also directly underlie AD. Although much has been established about the inflammatory processes in the pathogenesis of AD, many aspects remain unexplained. The work is devoted in particular to the pathomechanism of inflammation and its role in diagnosis and treatment. An in-depth and detailed understanding of the pathomechanism of neuroinflammation in Alzheimer's disease may help in the development of diagnostic methods for early diagnosis and may contribute to the development of new therapeutic strategies for the disease.
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Affiliation(s)
| | - Mariola Herbet
- Chair and Department of Toxicology, Faculty of Pharmacy, Medical University of Lublin, Jaczewskiego 8b Street, 20-090 Lublin, Poland
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17
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Liberman AL, Holl JL, Romo E, Maas M, Song S, Prabhakaran S. Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. Acad Emerg Med 2023; 30:187-195. [PMID: 36565234 DOI: 10.1111/acem.14648] [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: 09/15/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To date, many emergency department (ED)-based quality improvement studies and interventions for acute stroke patients have focused on expediting time-sensitive treatments, particularly reducing door-to-needle time. However, prior to treatment, a diagnosis of stroke must be reached. The ED-based stroke diagnostic process has been understudied despite its importance in assuring high-quality and safe care. METHODS We used a learning collaborative to conduct a failure modes, effects, and criticality analysis (FMECA) of the acute stroke diagnostic process at three health systems in Chicago, IL. Our FMECA was designed to prospectively identify, characterize, and rank order failures in the systems and processes of care that offer opportunities for redesign to improve stroke diagnostic accuracy. Multidisciplinary teams involved in stroke care at five different sites participated in moderated sessions to create an acute stroke diagnostic process map as well as identify failures and existing safeguards. For each failure, a risk priority number and criticality score were calculated. Failures were then ranked, with the highest scores representing the most critical failures to be targeted for redesign. RESULTS A total of 28 steps were identified in the acute stroke diagnostic process. Iterative steps in the process include information gathering, clinical examination, interpretation of diagnostic test results, and reassessment. We found that failure to use existing screening scales to identify patients with large-vessel occlusions early on in their ED course ranked highest. Failure to obtain an accurate history of the index event, failure to suspect acute stroke in triage, and failure to use established stroke screening tools at ED arrival to identify potential stroke patients were also highly ranked. CONCLUSIONS Our study results highlight the critical importance of upstream steps in the acute stroke diagnostic process, particularly the use of existing tools to identify stroke patients who may be eligible for time-sensitive treatments.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Jane L Holl
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elida Romo
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Matthew Maas
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Sarah Song
- Department of Neurology, Rush University, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
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18
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Young M, Szulewski A, Anderson R, Gomez-Garibello C, Thoma B, Monteiro S. Clinical Reasoning in CanMEDS 2025. CANADIAN MEDICAL EDUCATION JOURNAL 2023; 14:58-62. [PMID: 36998494 PMCID: PMC10042778 DOI: 10.36834/cmej.75843] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Meredith Young
- Institute of Health Sciences Education, McGill University, Quebec, Canada
| | | | | | | | - Brent Thoma
- University of Saskatchewan, Saskatchewan, Canada
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19
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Sader J, Diana A, Coen M, Nendaz M, Audétat MC. A GP's clinical reasoning in the context of multimorbidity: beyond the perception of an intuitive approach. Fam Pract 2023; 40:113-118. [PMID: 35849124 DOI: 10.1093/fampra/cmac076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION GP's clinical reasoning processes in the context of patients suffering from multimorbidity are often a process which remains implicit. Therefore, the goal of this case study analysis is to gain a better understanding of the processes at play in the management of patients suffering from multimorbidity. METHODS A case study analysis, using a qualitative thematic analysis was conducted. This case follows a 54-year-old woman who has been under the care of her GP for almost 10 years and suffers from a number of chronic conditions. The clinical reasoning of an experienced GP who can explicitly unfold his processes was chosen for this case analysis. RESULTS Four main themes emerged from this case analysis: The different roles that GPs have to manage; the GP's cognitive flexibility and continual adaptation of their clinical reasoning processes, the patient's empowerment, and the challenges related to the collaboration with specialists and healthcare professionals. CONCLUSION This could help GPs gain a clearer understanding of their clinical reasoning processes and motivate them to communicate their findings with others during clinical supervision or teaching. Furthermore, this may emphasize the importance of valuing the role of the primary care physician in the management of multimorbid patients.
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Affiliation(s)
- Julia Sader
- UDREM-Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,iEh2-Institute for Ethics, History, and the Humanities, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Alessandro Diana
- IuMFE-Institute of Primary Care, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Matteo Coen
- UDREM-Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,HUG-Department of Medicine, University Hospitals Geneva, Geneva, Switzerland
| | - Mathieu Nendaz
- UDREM-Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,HUG-Department of Medicine, University Hospitals Geneva, Geneva, Switzerland
| | - Marie-Claude Audétat
- UDREM-Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,IuMFE-Institute of Primary Care, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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20
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Choi JJ, Durning SJ. Context matters: toward a multilevel perspective on context in clinical reasoning and error. Diagnosis (Berl) 2022; 10:89-95. [PMID: 36480457 DOI: 10.1515/dx-2022-0117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/28/2022] [Indexed: 12/13/2022]
Abstract
Abstract
Context in diagnosis and management of patients is a vexing phenomenon in medicine and health professions education that can lead to unwanted variation in clinical reasoning performance and even errors that cause patient harm. Studies have examined individual-, team-, and system-level contextual factors, but the ways in which multiple contextual factors can interact, how both distracting and enabling factors can impact performance and error, and the boundaries between context and content information are not well understood. In this paper, we use a theory-based approach to enhance our understanding of context. We introduce a multilevel perspective on context that extends prior models of clinical reasoning and propose a micro-meso-macro framework to provide a more integrated understanding of how clinical reasoning is both influenced by and emerges from multiple contextual factors. The multilevel approach can also be used to study other social phenomena in medicine such as professionalism, learning, burnout, and implicit bias. We call for a new paradigm in clinical reasoning research and education that uses multilevel theory and analysis to enhance clinical reasoning performance expertise and improve the quality of patient care.
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Affiliation(s)
- Justin J. Choi
- Department of Medicine , Weill Cornell Medicine , New York , NY , USA
| | - Steven J. Durning
- Department of Medicine , Uniformed Services University of the Health Sciences , Bethesda , MD , USA
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21
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Brady PW, Marshall TL, Walsh KE. Promoting Action on Diagnostic Safety: The Safer Dx Checklist. Jt Comm J Qual Patient Saf 2022; 48:559-560. [PMID: 36155177 DOI: 10.1016/j.jcjq.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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22
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Redmond S, Barwise A, Zornes S, Dong Y, Herasevich S, Pinevich Y, Soleimani J, LeMahieu A, Leppin A, Pickering B. Contributors to Diagnostic Error or Delay in the Acute Care Setting: A Survey of Clinical Stakeholders. Health Serv Insights 2022; 15:11786329221123540. [PMID: 36119635 PMCID: PMC9476244 DOI: 10.1177/11786329221123540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
Diagnostic error or delay (DEOD) is common in the acute care setting and results in poor patient outcomes. Many factors contribute to DEOD, but little is known about how contributors may differ across acute care areas and professional roles. As part of a sequential exploratory mixed methods research study, we surveyed acute care clinical stakeholders about the frequency with which different factors contribute to DEOD. Survey respondents could also propose solutions in open text fields. N = 220 clinical stakeholders completed the survey. Care Team Interactions, Systems and Process, Patient, Provider, and Cognitive factors were perceived to contribute to DEOD with similar frequency. Organization and Infrastructure factors were perceived to contribute to DEOD significantly less often. Responses did not vary across acute care setting. Physicians perceived Cognitive factors to contribute to DEOD more frequently compared to those in other roles. Commonly proposed solutions included: technological solutions, organization level fixes, ensuring staff know and are encouraged to work to the full scope of their role, and cultivating a culture of collaboration and respect. Multiple factors contribute to DEOD with similar frequency across acute care areas, suggesting the need for a multi-pronged approach that can be applied across acute care areas.
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Affiliation(s)
- Sarah Redmond
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah Zornes
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yuliya Pinevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jalal Soleimani
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Allison LeMahieu
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic Rochester, Rochester, MN, USA
| | - Aaron Leppin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Knowledge and Evaluation Research Unit (KER), Mayo Clinic, Rochester, MN, USA
| | - Brian Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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23
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Yokose M, Harada Y, Hanai S, Tomiyama S, Shimizu T. Outcomes of General Internal Medicine Consultations for Diagnosis from Specialists in a Tertiary Hospital: A Retrospective Observational Study. Int J Gen Med 2022; 15:7209-7217. [PMID: 36124102 PMCID: PMC9482410 DOI: 10.2147/ijgm.s378146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 09/07/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose The data on the diagnostic contribution of general internal medicine (GIM) consultations for undiagnosed health problems from specialists are scarce. This study aims to explore the role of generalists as diagnostic medicine consultants in tertiary care settings. Patients and Methods We conducted a retrospective observational study at a Japanese university hospital. GIM consultations for diagnosis from other departments on outpatients aged ≧ 20 years from January 2018 to December 2020 were included. Data were extracted from electronic medical records. The primary outcome was new diagnosis rates. The secondary outcomes were new diagnosis rates with clinical significance and clinical outcomes at 90 days from the index visit. Results A total of 328 patients were included. The top five consulting departments were orthopedics (17.0%), cardiovascular (10.3%), otorhinolaryngology (8.8%), neurology (8.8%), and gastroenterology (7.9%). GIM identified 456 chief complaints (CCs), and the top five were fever (10.9%), abnormal laboratory results (8.3%), fatigue (5.9%), and pain (7.4%) or numbness (4.6%) in the extremities. There were 139 (104/328 patients: 31.8%) specialty consultations from GIM, and the top five departments were rheumatology (21.1%), gastroenterology (19.2%), orthopedics (9.6%), psychiatry (9.6%), and neurology (9.6%). In total, 277 new diagnoses were established in 232 patients (70.7%), and 203 patients had new diagnoses with clinical significance (61.8%). Clinical outcomes at 90 days from the time of the index visit were resolution/improvement (60.7%), unchanged/worsened (22.3%), and unknown (17.0%). Conclusion Over 70% of GIM consultations from other departments established new diagnoses with favorable outcomes in >60% of the patients.
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Affiliation(s)
- Masashi Yokose
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Mibu, Tochigi, 321-0293, Japan
| | - Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Mibu, Tochigi, 321-0293, Japan
| | - Shogo Hanai
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Mibu, Tochigi, 321-0293, Japan
| | - Shusaku Tomiyama
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Mibu, Tochigi, 321-0293, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Mibu, Tochigi, 321-0293, Japan
- Correspondence: Taro Shimizu, Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Kitakobayashi 880, Shimotsuga, Mibu, Tochigi, 321-0293, Japan, Tel +81 282 86-1111, Email
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24
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Fujimori T, Kijima T, Honda S, Yamagata S, Makiishi T. A Case of Acute Cerebral Infarction With Chief Complaints of Abdominal Pain and Bloody Diarrhoea: The Power of a Patient-Centered Inclusive Diagnostic Team. Cureus 2022; 14:e27386. [PMID: 36046325 PMCID: PMC9418667 DOI: 10.7759/cureus.27386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 11/05/2022] Open
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25
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Marshall TL, Rinke ML, Olson APJ, Brady PW. Diagnostic Error in Pediatrics: A Narrative Review. Pediatrics 2022; 149:184823. [PMID: 35230434 DOI: 10.1542/peds.2020-045948d] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 11/24/2022] Open
Abstract
A priority topic for patient safety research is diagnostic errors. However, despite the significant growth in awareness of their unacceptably high incidence and associated harm, a relative paucity of large, high-quality studies of diagnostic error in pediatrics exists. In this narrative review, we present what is known about the incidence and epidemiology of diagnostic error in pediatrics as well as the established research methods for identifying, evaluating, and reducing diagnostic errors, including their strengths and weaknesses. Additionally, we highlight that pediatric diagnostic error remains an area in need of both innovative research and quality improvement efforts to apply learnings from a rapidly growing evidence base. We propose several key research questions aimed at addressing persistent gaps in the pediatric diagnostic error literature that focus on the foundational knowledge needed to inform effective interventions to reduce the incidence of diagnostic errors and their associated harm. Additional research is needed to better establish the epidemiology of diagnostic error in pediatrics, including identifying high-risk clinical scenarios, patient populations, and groups of diagnoses. A critical need exists for validated measures of both diagnostic errors and diagnostic processes that can be adapted for different clinical settings and standardized for use across varying institutions. Pediatric researchers will need to work collaboratively on large-scale, high-quality studies to accomplish the ultimate goal of reducing diagnostic errors and their associated harm in children by addressing these fundamental gaps in knowledge.
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Affiliation(s)
- Trisha L Marshall
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michael L Rinke
- Department of Pediatrics, Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York
| | - Andrew P J Olson
- Departments of Medicine.,Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Patrick W Brady
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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Gordon D, Rencic JJ, Lang VJ, Thomas A, Young M, Durning SJ. Advancing the assessment of clinical reasoning across the health professions: Definitional and methodologic recommendations. PERSPECTIVES ON MEDICAL EDUCATION 2022; 11:108-114. [PMID: 35254653 PMCID: PMC8940991 DOI: 10.1007/s40037-022-00701-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 01/24/2022] [Accepted: 02/04/2022] [Indexed: 06/14/2023]
Abstract
The importance of clinical reasoning in patient care is well-recognized across all health professions. Validity evidence supporting high quality clinical reasoning assessment is essential to ensure health professional schools are graduating learners competent in this domain. However, through the course of a large scoping review, we encountered inconsistent terminology for clinical reasoning and inconsistent reporting of methodology, reflecting a somewhat fractured body of literature on clinical reasoning assessment. These inconsistencies impeded our ability to synthesize across studies and appropriately compare assessment tools. More specifically, we encountered: 1) a wide array of clinical reasoning-like terms that were rarely defined or informed by a conceptual framework, 2) limited details of assessment methodology, and 3) inconsistent reporting of the steps taken to establish validity evidence for clinical reasoning assessments. Consolidating our experience in conducting this review, we provide recommendations on key definitional and methodologic elements to better support the development, description, study, and reporting of clinical reasoning assessments.
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Affiliation(s)
- David Gordon
- Division of Emergency Medicine, Duke University, Durham, NC, USA.
| | - Joseph J Rencic
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Valerie J Lang
- Division of Hospital Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Aliki Thomas
- School of Physical and Occupational Therapy, Institute of Health Sciences Education, McGill University, Montreal, QC, Canada
| | - Meredith Young
- Department of Medicine and Institute of Health Sciences Education, McGill University, Montreal, QC, Canada
| | - Steven J Durning
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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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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Yousef EA, Sutcliffe KM, McDonald KM, Newman-Toker DE. Crossing Academic Boundaries for Diagnostic Safety: 10 Complex Challenges and Potential Solutions From Clinical Perspectives and High-Reliability Organizing Principles. HUMAN FACTORS 2022; 64:6-20. [PMID: 33657891 DOI: 10.1177/0018720821996187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE We apply the high-reliability organization (HRO) paradigm to the diagnostic process, outlining challenges to enacting HRO principles in diagnosis and offering solutions for how diagnostic process stakeholders can overcome these barriers. BACKGROUND Evidence shows that healthcare is starting to organize for higher reliability by employing various principles and practices of HRO. These hold promise for enhancing safer care, but there has been little consideration of the challenges that clinicians and healthcare systems face while enacting HRO principles in the diagnostic process. To effectively deploy the HRO perspective, these barriers must be seriously considered. METHOD We review key principles of the HRO paradigm, the diagnostic errors and harms that potentially can be prevented by its enactment, the challenges that clinicians and healthcare systems face in executing various principles and practices, and possible solutions that clinicians and organizational leaders can take to overcome these challenges and barriers. RESULTS Our analyses reveal multiple challenges including the inherent diagnostic uncertainty; the lack of diagnosis-focused performance feedback; the fact that diagnosis is often a solo, rather than team, activity; the tendency to simplify the diagnostic process; and professional and institutional status hierarchies. But these challenges are not insurmountable-there are strategies and solutions available to overcome them. CONCLUSION The HRO lens offers some important ideas for how the safety of the diagnostic process can be improved. APPLICATION The ideas proposed here can be enacted by both individual clinicians and healthcare leaders; both are necessary for making systematic progress in enhancing diagnostic performance.
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Affiliation(s)
- Elham A Yousef
- 24575 University Hospitals, Cleveland Medical Center. Case Western Reserve University, Ohio, USA
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Connor DM, Narayana S, Dhaliwal G. A clinical reasoning curriculum for medical students: an interim analysis. Diagnosis (Berl) 2022; 9:265-273. [PMID: 34904425 DOI: 10.1515/dx-2021-0112] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/22/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Diagnostic error is a critical patient safety issue that can be addressed in part through teaching clinical reasoning. Medical schools with clinical reasoning curricula tend to emphasize general reasoning concepts (e.g., differential diagnosis generation). Few published curricula go beyond teaching the steps in the diagnostic process to address how students should structure their knowledge to optimize diagnostic performance in future clinical encounters or to discuss elements outside of individual cognition that are essential to diagnosis. METHODS In 2016, the University of California, San Francisco School of Medicine launched a clinical reasoning curriculum that simultaneously emphasizes reasoning concepts and intentional knowledge construction; the roles of patients, families, interprofessional colleagues; and communication in diagnosis. The curriculum features a longitudinal thread beginning in first year, with an immersive three week diagnostic reasoning (DR) course in the second year. Students evaluated the DR course. Additionally, we conducted an audit of the multiyear clinical reasoning curriculum using the Society to Improve Diagnosis in Medicine-Macy Foundation interprofessional diagnostic education competencies. RESULTS Students rated DR highly (range 4.13-4.18/5 between 2018 and 2020) and reported high self-efficacy with applying clinical reasoning concepts and communicating reasoning to supervisors. A course audit demonstrated a disproportionate emphasis on individual (cognitive) competencies with inadequate attention to systems and team factors in diagnosis. CONCLUSIONS Our clinical reasoning curriculum led to high student self-efficacy. However, we stressed cognitive aspects of reasoning with limited instruction on teams and systems. Diagnosis education should expand beyond the cognitive- and physician-centric focus of most published reasoning courses.
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Affiliation(s)
- Denise M Connor
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Medical Service, San Francisco VA Medical Center, San Francisco, CA, USA
| | - Sirisha Narayana
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Gurpreet Dhaliwal
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Medical Service, San Francisco VA Medical Center, San Francisco, CA, USA
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Graber ML, Holmboe E, Stanley J, Danielson J, Schoenbaum S, Olson AP. A call to action: next steps to advance diagnosis education in the health professions. Diagnosis (Berl) 2021; 9:166-175. [PMID: 34881533 DOI: 10.1515/dx-2021-0103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/19/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Improving diagnosis-related education in the health professions has great potential to improve the quality and safety of diagnosis in practice. Twelve key diagnostic competencies have been delineated through a previous initiative. The objective of this project was to identify the next steps necessary for these to be incorporated broadly in education and training across the health professions. METHODS We focused on medicine, nursing, and pharmacy as examples. A literature review was conducted to survey the state of diagnosis education in these fields, and a consensus group was convened to specify next steps, using formal approaches to rank suggestions. RESULTS The literature review confirmed initial but insufficient progress towards addressing diagnosis-related education. By consensus, we identified the next steps necessary to advance diagnosis education, and five required elements relevant to every profession: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis. CONCLUSIONS The primary stakeholders, representing education, certification, accreditation, and licensure, in each profession must now take action in their own areas to encourage, promote, and enable improved diagnosis, and move these recommendations forward.
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Affiliation(s)
- Mark L Graber
- Society to Improve Diagnosis in Medicine, Plymouth, MA, USA
| | - Eric Holmboe
- Accreditation Council for Graduate Medical Education, Chicago, IL, USA
| | - Joan Stanley
- American Association of Colleges of Nursing, Washington, DC, USA
| | | | | | - Andrew Pj Olson
- University of Minnesota Medical School, Minneapolis, MN, USA
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Datta Gupta A. The art of diagnostic reasoning. Diagnosis (Berl) 2021; 9:390-392. [PMID: 34855310 DOI: 10.1515/dx-2021-0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Anupam Datta Gupta
- Central Adelaide Rehabilitation Services, The Queen Elizabeth Hospital, University of Adelaide, Woodville South, SA, Australia
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32
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Thompson B, Madan CR, Patel R. Investigating cognitive factors and diagnostic error in a presentation of complicated multisystem disease. Diagnosis (Berl) 2021; 9:199-206. [PMID: 34851562 DOI: 10.1515/dx-2021-0072] [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: 05/29/2021] [Accepted: 10/06/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To use a case review approach for investigating the types of cognitive error identifiable following a complicated patient admission with a multisystem disorder in an acute care setting where diagnosis was difficult and delayed. METHODS A case notes review was undertaken to explore the cognitive factors associated with diagnostic error in the case of an 18-year-old male presenting acutely unwell with myalgia, anorexia and vomiting. Each clinical interaction was analysed and identified cognitive factors were categorised using a framework developed by Graber et al. RESULTS Cognitive factors resulting in diagnostic errors most frequently occurred within the first five days of hospital admission. The most common were premature closure; failure to order or follow up an appropriate test; over-reliance on someone else's findings or opinion; over-estimating or underestimating usefulness or salience of a finding, and; ineffective, incomplete or faulty history and physical examination. Cognitive factors were particularly frequent around transitions of care and patient transfers from one clinical area to another. The presence of senior staff did not necessarily mitigate against diagnostic error from cognitive factors demonstrated by junior staff or diagnostic errors made out-of-hours. CONCLUSIONS Cognitive factors are a significant cause of diagnostic error within the first five days after admission, especially around transitions of care between different clinical settings and providers. Medical education interventions need to ensure clinical reasoning training supports individuals and teams to develop effective strategies for mitigating cognitive factors when faced with uncertainty over complex patients presenting with non-specific symptoms in order to reduce diagnostic error.
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Affiliation(s)
- Ben Thompson
- Critical Care Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Rakesh Patel
- School of Medicine, University of Nottingham, Nottingham, UK.,Nottingham University Hospitals NHS Trust, Nottingham, UK
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Bell SK, Bourgeois F, DesRoches CM, Dong J, Harcourt K, Liu SK, Lowe E, McGaffigan P, Ngo LH, Novack SA, Ralston JD, Salmi L, Schrandt S, Sheridan S, Sokol-Hessner L, Thomas G, Thomas EJ. Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. BMJ Qual Saf 2021; 31:526-540. [PMID: 34656982 DOI: 10.1136/bmjqs-2021-013672] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/29/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Patients and families are important contributors to the diagnostic team, but their perspectives are not reflected in current diagnostic measures. Patients/families can identify some breakdowns in the diagnostic process beyond the clinician's view. We aimed to develop a framework with patients/families to help organisations identify and categorise patient-reported diagnostic process-related breakdowns (PRDBs) to inform organisational learning. METHOD A multi-stakeholder advisory group including patients, families, clinicians, and experts in diagnostic error, patient engagement and safety, and user-centred design, co-developed a framework for PRDBs in ambulatory care. We tested the framework using standard qualitative analysis methods with two physicians and one patient coder, analysing 2165 patient-reported ambulatory errors in two large surveys representing 25 425 US respondents. We tested intercoder reliability of breakdown categorisation using the Gwet's AC1 and Cohen's kappa statistic. We considered agreement coefficients 0.61-0.8=good agreement and 0.81-1.00=excellent agreement. RESULTS The framework describes 7 patient-reported breakdown categories (with 40 subcategories), 19 patient-identified contributing factors and 11 potential patient-reported impacts. Patients identified breakdowns in each step of the diagnostic process, including missing or inaccurate main concerns and symptoms; missing/outdated test results; and communication breakdowns such as not feeling heard or misalignment between patient and provider about symptoms, events, or their significance. The frequency of PRDBs was 6.4% in one dataset and 6.9% in the other. Intercoder reliability showed good-to-excellent reliability in each dataset: AC1 0.89 (95% CI 0.89 to 0.90) to 0.96 (95% CI 0.95 to 0.97); kappa 0.64 (95% CI 0.62, to 0.66) to 0.85 (95% CI 0.83 to 0.88). CONCLUSIONS The PRDB framework, developed in partnership with patients/families, can help organisations identify and reliably categorise PRDBs, including some that are invisible to clinicians; guide interventions to engage patients and families as diagnostic partners; and inform whole organisational learning.
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Affiliation(s)
- Sigall K Bell
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Fabienne Bourgeois
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine M DesRoches
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joe Dong
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Kendall Harcourt
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen K Liu
- Department of Medicine, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Elizabeth Lowe
- Patient and Family Advisory Council, Department of Social Work, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Long H Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sandy A Novack
- Patient and Family Advisory Council, Department of Social Work, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Liz Salmi
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Suz Schrandt
- Society to Improve Diagnosis in Medicine, Evanston, Illinois, USA
| | - Sue Sheridan
- Society to Improve Diagnosis in Medicine, Evanston, Illinois, USA
| | - Lauge Sokol-Hessner
- Department of Medicine and Department of Health Care Quality, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Glenda Thomas
- Patient and Family Advisory Council, Department of Social Work, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eric J Thomas
- Department of Medicine, University of Texas McGovern Medical School, Houston, Texas, USA.,Healthcare Quality and Safety, Memorial Hermann Texas Medical Center, Houston, Texas, USA
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Lubin IM. Bringing the clinical laboratory into the strategy to advance diagnostic excellence. Diagnosis (Berl) 2021; 8:281-294. [PMID: 33554526 PMCID: PMC8255320 DOI: 10.1515/dx-2020-0119] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/16/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Clinical laboratory testing provides essential data for making medical diagnoses. Generating accurate and timely test results clearly communicated to the treating clinician, and ultimately the patient, is a critical component that supports diagnostic excellence. On the other hand, failure to achieve this can lead to diagnostic errors that manifest in missed, delayed and wrong diagnoses. CONTENT Innovations that support diagnostic excellence address: 1) test utilization, 2) leveraging clinical and laboratory data, 3) promoting the use of credible information resources, 4) enhancing communication among laboratory professionals, health care providers and the patient, and 5) advancing the use of diagnostic management teams. Integrating evidence-based laboratory and patient-care quality management approaches may provide a strategy to support diagnostic excellence. Professional societies, government agencies, and healthcare systems are actively engaged in efforts to advance diagnostic excellence. Leveraging clinical laboratory capabilities within a healthcare system can measurably improve the diagnostic process and reduce diagnostic errors. SUMMARY An expanded quality management approach that builds on existing processes and measures can promote diagnostic excellence and provide a pathway to transition innovative concepts to practice. OUTLOOK There are increasing opportunities for clinical laboratory professionals and organizations to be part of a strategy to improve diagnoses.
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Affiliation(s)
- Ira M. Lubin
- Division of Laboratory Systems, Centers for Disease Control and Prevention, 1600 Clifton Rd., NE Mail Stop V24-3, GA 30329, Atlanta, GA, USA
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35
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Samuel LP, Hansen GT, Kraft CS, Pritt BS. The Need for Dedicated Microbiology Leadership in the Clinical Microbiology Laboratory. J Clin Microbiol 2021; 59:e0154919. [PMID: 33597258 PMCID: PMC8288296 DOI: 10.1128/jcm.01549-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Clinical microbiology laboratories play a crucial role in patient care using traditional and innovative diagnostics. Challenges faced by laboratories include emerging pathogens, rapidly evolving technologies, health care-acquired infections, antibiotic-resistant organisms, and diverse patient populations. Despite these challenges, many clinical microbiology laboratories in the United States are not directed by doctoral level microbiology-trained individuals with sufficient time dedicated to laboratory leadership. The manuscript highlights the need for medical microbiology laboratory directors with appropriate training and qualifications.
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Affiliation(s)
- Linoj P. Samuel
- Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - Glen T. Hansen
- Department of Pathology and Laboratory Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Pathology and Laboratory Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Medicine, Division of Infectious Diseases, University of Minnesota, Minneapolis, Minnesota, USA
| | - Colleen S. Kraft
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
- Department Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Bobbi S. Pritt
- Department of Laboratory Medicine and Pathology, Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Internal Medicine, Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
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Gleason K, Harkless G, Stanley J, Olson APJ, Graber ML. The critical need for nursing education to address the diagnostic process. Nurs Outlook 2021; 69:362-369. [PMID: 33455815 PMCID: PMC8178169 DOI: 10.1016/j.outlook.2020.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/10/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
Diagnostic errors are among the most common medical errors and the deadliest. The National Academy of Medicine recently concluded that diagnostic errors represent an urgent national concern. Their first recommendation to address this issue called for promoting the key role of the nurse in the diagnostic process. Registered nurses across clinical settings significantly contribute to the medical diagnostic process, though their role in diagnosis has historically gone unacknowledged. In this paper, we review the history and current state of diagnostic education in pre-licensure registered nurse preparation, introduce interprofessional individual- and team-based competencies to improve diagnostic safety, and discuss the next steps for nursing education. Nurses educated and empowered to fully participate in the diagnostic process are essential for achieving better, safer patient outcomes.
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Affiliation(s)
| | | | - Joan Stanley
- American Association of Colleges of Nursing, Washington, DC
| | | | - Mark L Graber
- Society to Improve Diagnosis in Medicine, Chicago, IL
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Bergl PA, Wijesekera TP, Nassery N, Cosby KS. Controversies in diagnosis: contemporary debates in the diagnostic safety literature. ACTA ACUST UNITED AC 2020; 7:3-9. [PMID: 31129651 DOI: 10.1515/dx-2019-0016] [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: 03/01/2019] [Accepted: 04/28/2019] [Indexed: 11/15/2022]
Abstract
Since the 2015 publication of the National Academy of Medicine's (NAM) Improving Diagnosis in Health Care (Improving Diagnosis in Health Care. In: Balogh EP, Miller BT, Ball JR, editors. Improving Diagnosis in Health Care. Washington (DC): National Academies Press, 2015.), literature in diagnostic safety has grown rapidly. This update was presented at the annual international meeting of the Society to Improve Diagnosis in Medicine (SIDM). We focused our literature search on articles published between 2016 and 2018 using keywords in Pubmed and the Agency for Healthcare Research and Quality (AHRQ)'s Patient Safety Network's running bibliography of diagnostic error literature (Diagnostic Errors Patient Safety Network: Agency for Healthcare Research and Quality; Available from: https://psnet.ahrq.gov/search?topic=Diagnostic-Errors&f_topicIDs=407). Three key topics emerged from our review of recent abstracts in diagnostic safety. First, definitions of diagnostic error and related concepts are evolving since the NAM's report. Second, medical educators are grappling with new approaches to teaching clinical reasoning and diagnosis. Finally, the potential of artificial intelligence (AI) to advance diagnostic excellence is coming to fruition. Here we present contemporary debates around these three topics in a pro/con format.
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Affiliation(s)
- Paul A Bergl
- Assistant Professor of Medicine in the Division of Pulmonary, Critical Care, and Sleep Medicine, Froedtert and the Medical College of Wisconsin, Hub for Collaborative Medicine, 8th Floor, 8701 W. Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Thilan P Wijesekera
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Najlla Nassery
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen S Cosby
- Department of Emergency Medicine, Rush Medical College, Chicago, IL, USA
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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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Oliveira AL, Brown M. SBAR as a Standardized Communication Tool for Medical Laboratory Science Students. Lab Med 2020; 52:136-140. [PMID: 32851414 DOI: 10.1093/labmed/lmaa061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Laboratory professionals must communicate effectively on an interprofessional team. It is the responsibility of Medical Laboratory Science (MLS) programs to teach communication. The structured communication tool Situation, Background, Assessment, and Recommendation (SBAR) is one way to promote effective communication. METHODS Students participated in a case-based simulation activity on the importance of teamwork/communication and the use of SBAR and completed a pre/post survey on communicating interprofessionally. RESULTS Students reported increased confidence and competence with interprofessional communication after the activity with 4 of 5 questions demonstrating a statistically significant increase in scores post SBAR instruction. CONCLUSIONS Our study demonstrates that SBAR is a suitable communication tool that can be used to increase our MLS students' confidence and competency in interprofessional communication. Educators should use this communication tool to empower MLS students to be effective members of the healthcare team.
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Affiliation(s)
- Ana L Oliveira
- Department of Clinical and Diagnostic Sciences, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michelle Brown
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama.,Office of Interprofessional Simulation for Innovative Clinical Practice University of Alabama at Birmingham, Birmingham, Alabama
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Olson AP, Graber ML. Improving Diagnosis Through Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1162-1165. [PMID: 31977340 PMCID: PMC7382536 DOI: 10.1097/acm.0000000000003172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Diagnosis is the cornerstone of providing safe and effective medical care. Still, diagnostic errors are all too common. A key to improving diagnosis in practice is improving diagnosis education, yet formal education about diagnosis is often lacking, idiosyncratic, and not evidence based. In this Invited Commentary, the authors describe the outcomes of a national consensus project to identify key competencies for diagnosis and the themes that emerged as part of this work. The 12 competencies the authors describe span 3 categories-individual, teamwork, and system related-and address ideal diagnostic practice for all health professionals. In addition, the authors identify strategies for improving diagnosis education, including the use of theory-based pedagogy and interprofessional approaches, the recognition of the role of the health care system to enhance or inhibit the diagnostic process, and the need to focus on the individual attributes necessary for high-quality diagnosis, such as humility and curiosity. The authors conclude by advocating for increasing and improving the assessment of individual and team-based diagnostic performance in health professions education programs.
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Affiliation(s)
- Andrew P.J. Olson
- A.P.J. Olson is associate professor, Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Mark L. Graber
- M.L. Graber is chief medical officer, Society to Improve Diagnosis in Medicine, New York, New York
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Olson APJ, Durning SJ, Fernandez Branson C, Sick B, Lane KP, Rencic JJ. Teamwork in clinical reasoning - cooperative or parallel play? ACTA ACUST UNITED AC 2020; 7:307-312. [PMID: 32697754 DOI: 10.1515/dx-2020-0020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/25/2020] [Indexed: 11/15/2022]
Abstract
Teamwork is fundamental for high-quality clinical reasoning and diagnosis, and many different individuals are involved in the diagnostic process. However, there are substantial gaps in how these individuals work as members of teams and, often, work is done in parallel, rather than in an integrated, collaborative fashion. In order to understand how individuals work together to create knowledge in the clinical context, it is important to consider social cognitive theories, including situated cognition and distributed cognition. In this article, the authors describe existing gaps and then describe these theories as well as common structures of teams in health care and then provide ideas for future study and improvement.
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Affiliation(s)
- Andrew P J Olson
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.,Departments of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Steven J Durning
- Departments of Medicine and Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Brian Sick
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.,Departments of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kathleen P Lane
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Joseph J Rencic
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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Graber ML. Progress understanding diagnosis and diagnostic errors: thoughts at year 10. Diagnosis (Berl) 2020; 7:151-159. [DOI: 10.1515/dx-2020-0055] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/02/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Mark L. Graber
- Society to Improve Diagnosis in Medicine , Evanston , IL , USA
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43
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Duthie EA, Fischer IC, Frankel RM. Blame and its consequences for healthcare professionals: response to Tigard. JOURNAL OF MEDICAL ETHICS 2020; 46:339-341. [PMID: 31649111 DOI: 10.1136/medethics-2019-105525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 08/01/2019] [Accepted: 08/07/2019] [Indexed: 06/10/2023]
Abstract
Tigard (2019) suggests that the medical community would benefit from continuing to promote notions of individual responsibility and blame in healthcare settings. In particular, he contends that blame will promote systematic improvement, both on the individual and institutional levels, by increasing the likelihood that the blameworthy party will 'own up' to his or her mistake and apologise. While we agree that communicating regret and offering a genuine apology are critical steps to take when addressing patient harm, the idea that medical professionals should continue to 'take the blame' for medical errors flies in the face of existing science and threatens to do more harm than good. We contrast Dr Tigard's approach with the current literature on blame to promote an alternative strategy that may help to create lasting change in the face of unfortunate error.
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Affiliation(s)
- Elizabeth A Duthie
- Patient Safety Resource Center, Montefiore Health System, Bronx, New York, USA
| | - Ian C Fischer
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, USA
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44
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Dadlez NM, Adelman J, Bundy DG, Singh H, Applebaum JR, Rinke ML. Contributing Factors for Pediatric Ambulatory Diagnostic Process Errors: Project RedDE. Pediatr Qual Saf 2020; 5:e299. [PMID: 32656467 PMCID: PMC7297397 DOI: 10.1097/pq9.0000000000000299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 04/15/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Pediatric ambulatory diagnostic errors (DEs) occur frequently. We used root cause analyses (RCAs) to identify their failure points and contributing factors. METHODS Thirty-one practices were enrolled in a national QI collaborative to reduce 3 DEs occurring at different stages of the diagnostic process: missed adolescent depression, missed elevated blood pressure (BP), and missed actionable laboratory values. Practices were encouraged to perform monthly "mini-RCAs" to identify failure points and prioritize interventions. Information related to process steps involved, specific contributing factors, and recommended interventions were reported monthly. Data were analyzed using descriptive statistics and Pareto charts. RESULTS Twenty-eight (90%) practices submitted 184 mini-RCAs. The median number of mini-RCAs submitted was 6 (interquartile range, 2-9). For missed adolescent depression, the process step most commonly identified was the failure to screen (68%). For missed elevated BP, it was the failure to recognize (36%) and act on (28%) abnormal BP. For missed actionable laboratories, failure to notify families (23%) and document actions on (19%) abnormal results were the process steps most commonly identified. Top contributing factors to missed adolescent depression included patient volume (16%) and inadequate staffing (13%). Top contributing factors to missed elevated BP included patient volume (12%), clinic milieu (9%), and electronic health records (EHRs) (8%). Top contributing factors to missed actionable laboratories included written communication (13%), EHR (9%), and provider knowledge (8%). Recommended interventions were similar across errors. CONCLUSIONS EHR-based interventions, standardization of processes, and cross-training may help decrease DEs in the pediatric ambulatory setting. Mini-RCAs are useful tools to identify their contributing factors and interventions.
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Affiliation(s)
- Nina M. Dadlez
- From the Department of Pediatrics, Floating Hospital for Children at Tufts Medical Center and Tufts University School of Medicine, Boston, Mass
| | - Jason Adelman
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, N.Y
| | - David G. Bundy
- Department of Pediatrics, Medical University of South Carolina, Charleston, S.C
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Department of Medicine, Baylor College of Medicine, Center of Innovation, Houson, Tex
| | - Jo R. Applebaum
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, N.Y
| | - Michael L. Rinke
- Department of Pediatrics, The Children’s Hospital at Montefiore and The Albert Einstein College of Medicine, Bronx, N.Y
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45
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Merkebu J, Battistone M, McMains K, McOwen K, Witkop C, Konopasky A, Torre D, Holmboe E, Durning SJ. Situativity: a family of social cognitive theories for understanding clinical reasoning and diagnostic error. Diagnosis (Berl) 2020; 7:169-176. [DOI: 10.1515/dx-2019-0100] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/11/2020] [Indexed: 11/15/2022]
Abstract
Abstract
The diagnostic error crisis suggests a shift in how we view clinical reasoning and may be vital for transforming how we view clinical encounters. Building upon the literature, we propose clinical reasoning and error are context-specific and proceed to advance a family of theories that represent a model outlining the complex interplay of physician, patient, and environmental factors driving clinical reasoning and error. These contemporary social cognitive theories (i.e. embedded cognition, ecological psychology, situated cognition, and distributed cognition) can emphasize the dynamic interactions occurring amongst participants in particular settings. The situational determinants that contribute to diagnostic error are also explored.
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Affiliation(s)
- Jerusalem Merkebu
- Uniformed Services University of the Health Sciences (USUHS) , Bethesda , USA
| | - Michael Battistone
- George E. Wahlen Veterans Affairs Salt Lake City Health Care System USA, Department of Medicine, Division of Rheumatology, University of Utah Health Sciences Center , Salt Lake City , USA
| | - Kevin McMains
- Uniformed Services University of the Health Sciences (USUHS) , Bethesda , USA
| | - Kathrine McOwen
- Association of American Medical Colleges (AAMC) , Uniformed Services University of the Health Sciences (USUHS) , Bethesda , USA
| | - Catherine Witkop
- Obstetrics/Gynecology and Preventive Medicine , Uniformed Services University of the Health Sciences (USUHS) , Bethesda , USA
| | - Abigail Konopasky
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences (USUHS) , Bethesda , USA
| | - Dario Torre
- Uniformed Services University of the Health Sciences (USUHS) , Bethesda , USA
| | - Eric Holmboe
- Accreditation Council for Graduate Medical Education (ACGME), Uniformed Services University of the Health Sciences (USUHS) , Chicago, IL , USA
| | - Steven J. Durning
- Uniformed Services University of the Health Sciences (USUHS) , Bethesda , USA
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46
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Young ME, Thomas A, Lubarsky S, Gordon D, Gruppen LD, Rencic J, Ballard T, Holmboe E, Da Silva A, Ratcliffe T, Schuwirth L, Dory V, Durning SJ. Mapping clinical reasoning literature across the health professions: a scoping review. BMC MEDICAL EDUCATION 2020; 20:107. [PMID: 32264895 PMCID: PMC7140328 DOI: 10.1186/s12909-020-02012-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 03/19/2020] [Indexed: 05/10/2023]
Abstract
BACKGROUND Clinical reasoning is at the core of health professionals' practice. A mapping of what constitutes clinical reasoning could support the teaching, development, and assessment of clinical reasoning across the health professions. METHODS We conducted a scoping study to map the literature on clinical reasoning across health professions literature in the context of a larger Best Evidence Medical Education (BEME) review on clinical reasoning assessment. Seven databases were searched using subheadings and terms relating to clinical reasoning, assessment, and Health Professions. Data analysis focused on a comprehensive analysis of bibliometric characteristics and the use of varied terminology to refer to clinical reasoning. RESULTS Literature identified: 625 papers spanning 47 years (1968-2014), in 155 journals, from 544 first authors, across eighteen Health Professions. Thirty-seven percent of papers used the term clinical reasoning; and 110 other terms referring to the concept of clinical reasoning were identified. Consensus on the categorization of terms was reached for 65 terms across six different categories: reasoning skills, reasoning performance, reasoning process, outcome of reasoning, context of reasoning, and purpose/goal of reasoning. Categories of terminology used differed across Health Professions and publication types. DISCUSSION Many diverse terms were present and were used differently across literature contexts. These terms likely reflect different operationalisations, or conceptualizations, of clinical reasoning as well as the complex, multi-dimensional nature of this concept. We advise authors to make the intended meaning of 'clinical reasoning' and associated terms in their work explicit in order to facilitate teaching, assessment, and research communication.
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Affiliation(s)
- Meredith E. Young
- Institute of Health Sciences Education in the Faculty of Medicine, McGill University, Room 200 Lady Meredith House, 1110 Pine Avenue West, Montreal, QC H3A 1A3 Canada
| | - Aliki Thomas
- School of Physical and Occupational Therapy, Institute of Health Sciences Education in the Faculty of Medicine at McGill University, Centre for Interdisciplinary Research in Rehabilitation of greater Montreal, Montréal, Canada
| | - Stuart Lubarsky
- Department of Neurology and Institute of Health Sciences Education, McGill University, Montreal, Canada
| | - David Gordon
- Division of Emergency Medicine and the Department of Surgery, Duke University School of Medicine, Durham, North Carolina USA
| | - Larry D. Gruppen
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, USA
| | - Joseph Rencic
- Division of General Internal Medicine at Tufts Medical Center, Tufts University School of Medicine, Boston, MA USA
| | | | - Eric Holmboe
- Chief Research, Milestone Development, and Evaluation Officer, ACGME, Chicago, IL USA
- Feinberg School of Medicine of Northwestern University, Chicago, IL USA
| | | | - Temple Ratcliffe
- Department of Medicine, University of Texas Health Science Center, San Antonio, TX USA
| | - Lambert Schuwirth
- Flinders University, Adelaide, Australia
- Maastricht University, Maastricht, Netherlands
- Chang Gung University, Taoyuan City, Taiwan
- Uniformed Services University of the Health Sciences, Bethesda, USA
| | - Valérie Dory
- Department of Medicine, an Assessment Specialist for undergraduate medical education in the Faculty of Medicine, McGill University, Montreal, Canada
| | - Steven J. Durning
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD USA
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47
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Olson A, Rencic J, Cosby K, Rusz D, Papa F, Croskerry P, Zierler B, Harkless G, Giuliano MA, Schoenbaum S, Colford C, Cahill M, Gerstner L, Grice GR, Graber ML. Competencies for improving diagnosis: an interprofessional framework for education and training in health care. ACTA ACUST UNITED AC 2020; 6:335-341. [PMID: 31271549 DOI: 10.1515/dx-2018-0107] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 05/05/2019] [Indexed: 01/06/2023]
Abstract
Background Given an unacceptably high incidence of diagnostic errors, we sought to identify the key competencies that should be considered for inclusion in health professions education programs to improve the quality and safety of diagnosis in clinical practice. Methods An interprofessional group reviewed existing competency expectations for multiple health professions, and conducted a search that explored quality, safety, and competency in diagnosis. An iterative series of group discussions and concept prioritization was used to derive a final set of competencies. Results Twelve competencies were identified: Six of these are individual competencies: The first four (#1-#4) focus on acquiring the key information needed for diagnosis and formulating an appropriate, prioritized differential diagnosis; individual competency #5 is taking advantage of second opinions, decision support, and checklists; and #6 is using reflection and critical thinking to improve diagnostic performance. Three competencies focus on teamwork: Involving the patient and family (#1) and all relevant health professionals (#2) in the diagnostic process; and (#3) ensuring safe transitions of care and handoffs, and "closing the loop" on test result communication. The final three competencies emphasize system-related aspects of care: (#1) Understanding how human-factor elements influence the diagnostic process; (#2) developing a supportive culture; and (#3) reporting and disclosing diagnostic errors that are recognized, and learning from both successful diagnosis and from diagnostic errors. Conclusions These newly defined competencies are relevant to all health professions education programs and should be incorporated into educational programs.
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Affiliation(s)
- Andrew Olson
- Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Joseph Rencic
- Internal Medicine Residency Program, Tufts University School of Medicine, Boston, MA, USA
| | | | - Diana Rusz
- Society to Improve Diagnosis in Medicine, Chicago, IL, USA
| | - Frank Papa
- University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Pat Croskerry
- Department of Emergency Medicine, Dalhousie University Medical School, Halifax, Nova Scotia, Canada
| | - Brenda Zierler
- University of Washington School of Nursing, Seattle, WA, USA
| | | | - Michael A Giuliano
- Hackensack Meridian School of Medicine at Seton Hall, South Orange, NJ, USA
| | | | - Cristin Colford
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Maureen Cahill
- National Council State Boards of Nursing, Chicago, IL, USA
| | - Laura Gerstner
- Campbell University Physician Assistant Program, Buies Creek, NC, USA
| | | | - Mark L Graber
- Chief Medical Officer, Society to Improve Diagnosis in Medicine, New York, NY, USA
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48
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Sorace J. Payment Reform in the Era of Advanced Diagnostics, Artificial Intelligence, and Machine Learning. J Pathol Inform 2020; 11:6. [PMID: 32175171 PMCID: PMC7047746 DOI: 10.4103/jpi.jpi_63_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 11/21/2019] [Accepted: 12/24/2019] [Indexed: 11/28/2022] Open
Abstract
Health care is undergoing a profound transformation driven by an increase in new types of diagnostic data, increased data sharing enabled by interoperability, and improvements in our ability to interpret data through the application of artificial intelligence and machine learning. Paradoxically, we are also discovering that our current paradigms for implementing electronic health-care records and our ability to create new models for reforming the health-care system have fallen short of expectations. This article traces these shortcomings to two basic issues. The first is a reliance on highly centralized quality improvement and measurement strategies that fail to account for the high level of variation and complexity found in human disease. The second is a reliance on legacy payment systems that fail to reward the sharing of data and knowledge across the health-care system. To address these issues, and to better harness the advances in health care noted above, the health-care system must undertake a phased set of reforms. First, efforts must focus on improving both the diagnostic process and data sharing at the local level. These efforts should include the formation of diagnostic management teams and increased collaboration between pathologists and radiologists. Next, building off current efforts to develop national federated research databases, providers must be able to query national databases when information is needed to inform the care of a specific complex patient. In addition, providers, when treating a specific complex patient, should be enabled to consult nationally with other providers who have experience with similar patient issues. The goal of these efforts is to build a health-care system that is funded in part by a novel fee-for-knowledge-sharing paradigm that fosters a collaborative decentralized approach to patient care and financially incentivizes large-scale data and knowledge sharing.
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Affiliation(s)
- James Sorace
- Retired Medical Officer U.S. Department of Health and Human Services, Washington, D.C., USA
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49
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Church DL, Naugler C. Essential role of laboratory physicians in transformation of laboratory practice and management to a value-based patient-centric model. Crit Rev Clin Lab Sci 2020; 57:323-344. [PMID: 32180485 DOI: 10.1080/10408363.2020.1720591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The laboratory is a vital part of the continuum of patient care. In fact, there are few programs in the healthcare system that do not rely on ready access and availability of complex diagnostic laboratory services. The existing transactional model of laboratory "medical practice" will not be able to meet the needs of the healthcare system as it rapidly shifts toward value-based care and precision medicine, which demands that practice be based on total system indicators, clinical effectiveness, and patient outcomes. Laboratory "value" will no longer be focused primarily on internal testing quality and efficiencies but rather on the relative cost of diagnostic testing compared to direct improvement in clinical and system outcomes. The medical laboratory as a "business" focused on operational efficiency and cost-controls must transform to become an essential clinical service that is a tightly integrated equal partner in direct patient care. We would argue that this paradigm shift would not be necessary if laboratory services had remained a "patient-centric" medical practice throughout the last few decades. This review is focused on the essential role of laboratory physicians in transforming laboratory practice and management to a value-based patient-centric model. Value-based practice is necessary not only to meet the challenges of the new precision medicine world order but also to bring about sustainable healthcare service delivery.
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Affiliation(s)
- Deirdre L Church
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Naugler
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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50
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Chua I, Petrides AK, Schiff GD, Ransohoff JR, Kantartjis M, Streid J, Demetriou CA, Melanson SEF. Provider Misinterpretation, Documentation, and Follow-Up of Definitive Urine Drug Testing Results. J Gen Intern Med 2020; 35:283-290. [PMID: 31713040 PMCID: PMC6957646 DOI: 10.1007/s11606-019-05514-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/13/2019] [Accepted: 10/02/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Urine drug testing (UDT) is an essential tool to monitor opioid misuse among patients on chronic opioid therapy. Inaccurate interpretation of UDT can have deleterious consequences. Providers' ability to accurately interpret and document UDT, particularly definitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) results, has not been widely studied. OBJECTIVE To examine whether providers correctly interpret, document, and communicate LC-MS/MS UDT results. DESIGN This is a retrospective chart review of 160 UDT results (80 aberrant; 80 non-aberrant) between August 2017 and February 2018 from 5 ambulatory clinics (3 primary care, 1 oncology, 1 pain management). Aberrant results were classified into one or more of the following categories: illicit drug use, simulated compliance, not taking prescribed medication, and taking a medication not prescribed. Accurate result interpretation was defined as concordance between the provider's documented interpretation and an expert laboratory toxicologist's interpretation. Outcome measures were concordance between provider and laboratory interpretation of UDT results, documentation of UDT results, results acknowledgement in the electronic health record, communication of results to the patient, and rate of prescription refills. KEY RESULTS Aberrant results were most frequently due to illicit drug use. Overall, only 88 of the 160 (55%) had any documented provider interpretations of which 25/88 (28%) were discordant with the laboratory toxicologist's interpretation. Thirty-six of the 160 (23%) documented communication of the results to the patient. Communicating results was more likely to be documented if the results were aberrant compared with non-aberrant (33/80 [41%] vs. 3/80 [4%], p < 0.001). In all cases where provider interpretations were discordant with the laboratory interpretation, prescriptions were refilled. CONCLUSIONS Erroneous provider interpretation of UDT results, infrequent documentation of interpretation, lack of communication of results to patients, and prescription refills despite inaccurate interpretations are common. Expert assistance with urine toxicology interpretations may be needed to improve provider accuracy when interpreting toxicology results.
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Affiliation(s)
- Isaac Chua
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Athena K Petrides
- Harvard Medical School, Boston, MA, USA
- Department of Pathology , Brigham and Women's Hospital, Boston, MA, USA
| | - Gordon D Schiff
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jaime R Ransohoff
- Department of Pathology , Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michalis Kantartjis
- Department of Pathology , Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jocelyn Streid
- Harvard Medical School, Boston, MA, USA
- Harvard Kennedy School, Boston, MA, USA
| | - Christiana A Demetriou
- Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus
- The Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Stacy E F Melanson
- Harvard Medical School, Boston, MA, USA.
- Department of Pathology , Brigham and Women's Hospital, Boston, MA, USA.
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