Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors

Identifying Facilitators and Inhibitors of Shared Understanding: An Ethnography of Diagnosis Communication in Acute Medical Settings

BACKGROUND AND AIMS

Communication is important in determining how patients understand the diagnostic process. Empirical studies involving direct observation of communication within diagnostic processes are relatively limited. This ethnographic study aimed to identify communicative practices facilitating or inhibiting shared understanding between patients and doctors in UK acute secondary care settings.

METHODS

Data were collected in acute medical sectors of three English hospitals. Researchers observed doctors as they assessed patients; semistructured interviews were undertaken with doctors and patients directly afterwards. Patients were also interviewed 2-4 weeks later. Case studies of individual encounters (consisting of these interviews and observational notes) were created, and were cross-examined by an interdisciplinary team to identify divergence and convergence between doctors' and patients' narratives. These data were analysed thematically.

RESULTS

We conducted 228 h of observation, 24 doctor interviews, 32 patient interviews and 15 patient follow-up interviews. Doctors varied in their communication. Patient diagnostic understanding was sometimes misaligned with that of their doctors; interviews revealed that they often made incorrect assumptions to make sense of the fragmented information received. Thematic analysis identified communicative practices that seemed to facilitate, or inhibit, shared diagnostic understanding between patient and doctor, revealing three themes: (1) communicating what has been understood from the medical record, (2) sharing the thought process and diagnostic reasoning and (3) closing the loop and discharge communication. Shared understanding was best fostered by clear communication about the diagnostic process, what had already been done and what was achievable in acute settings. Written information presents an underutilised tool in such communication.

CONCLUSIONS

In UK acute secondary settings, the provision of more information about the diagnostic process often fostered shared understanding between doctor and patient, helping to minimise the confusion and dissatisfaction that can result from misaligned expectations or conclusions about the diagnosis, and the uncertainty therein.

PATIENT/PUBLIC CONTRIBUTION

A patient and public involvement group (of a range of ages and backgrounds) was consulted. They contributed to the design of the protocol, including the timing of interviews, the acceptability of a follow-up telephone interview, the development of the interview guides and the participant information sheets.

Associations Between Hospitalist Shift Busyness, Diagnostic Confidence, and Resource Utilization: A Pilot Study

OBJECTIVES

Hospitalized patients are at risk for diagnostic errors. Hospitalists caring for these patients are often multitasking when overseeing patient care. We aimed to measure hospitalist workload and understand its influences on diagnostic performance in a real-world clinical setting.

METHODS

We conducted a single-center, prospective, pilot observational study of hospitalists admitting new patients to the hospital. Hospitalists completed an abridged Mindful Attention Awareness Tool and a survey about diagnostic confidence at shift completion. Data on differential diagnoses and resource utilization (e.g., laboratory, imaging tests ordered, and consultations) were collected from the medical record. The number of admissions and paging volume per shift were used as separate proxies for shift busyness. Data were analyzed using linear mixed effects models (continuous outcomes) or mixed effects logistic regression (dichotomous outcomes).

RESULTS

Of the 53 hospitalists approached, 47 (89%) agreed to participate; complete data were available for 37 unique hospitalists who admitted 160 unique patients. Increases in admissions (odds ratio, 1.99; 95% confidence interval [CI], 1.04 to 3.82; P = 0.04) and pages (odds ratio, 1.11; 95% CI, 1.02 to 1.21; P = 0.01) were associated with increased odds of hospitalists finding it "difficult to focus on what is happening in the present." Increased pages was associated with a decrease in the number of listed differential diagnoses (coefficient, -0.02; 95% CI, -0.04 to -0.003; P = 0.02).

CONCLUSIONS

Evaluation of hospitalist busyness and its associations with factors that may influence diagnosis in a real-world environment was feasible and demonstrated important implications on physician focus and differential diagnosis.

Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda

Interruptions are an inevitable occurrence in health care. Interruptions in diagnostic decision-making are no exception and can have negative consequences on both the decision-making process and well-being of the decision-maker. This may result in inaccurate or delayed diagnoses. To date, research specific to interruptions on diagnostic decision-making has been limited, but strategies to help manage the negative impacts of interruptions need to be developed and implemented. In this perspective, we first present a modified model of interruptions to visualize the interruption process and illustrate where potential interventions can be implemented. We then consider several empirically tested strategies from the fields of health care and cognitive psychology that can lay the groundwork for additional research to mitigate effects of interruptions during diagnostic decision-making. We highlight strategies to minimize the negative impacts of interruptions as well as strategies to prevent interruptions altogether. Additionally, we build upon these strategies to propose specific research priorities within the field of diagnostic safety. Identifying effective interventions to help clinicians better manage interruptions has the potential to minimize diagnostic errors and improve patient outcomes.

Context matters: toward a multilevel perspective on context in clinical reasoning and error

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.

Pursuit of "endpoint diagnoses" as a cognitive forcing strategy to avoid premature diagnostic closure

Premature closure is often described as a significant contributor to diagnostic error. Therefore, developing strategies to mitigate premature closure could reduce diagnostic errors and improve patient care. Here we propose the novel concept of pursuit of an "endpoint diagnosis" as a cognitive forcing strategy (CFS) for avoiding premature diagnostic closure. We define an "endpoint diagnosis" as an underlying causative explanation for a patient's signs, symptoms, and laboratory and radiographic data that exhausts additional relevant diagnostic evaluation. We have observed four contexts in which the error of not pursuing an endpoint diagnosis most often occurs: (1) diagnoses that appear to result in the same treatment regardless of etiology, (2) cases that are particularly complex, (3) clinical scenarios that are vulnerable to systems errors, and (4) situations in which patients' problems are attributed to uncontrolled underlying risk factors or an exacerbation of a known condition. Additionally, we address why we believe endpoint diagnoses are not universally pursued, delineate when this approach might be particularly useful, attempt to reconcile the potential conflict between accepting diagnostic ambiguity in certain instances and pursuing endpoint diagnoses, and outline possible concerns that might arise with using this CFS, including the possibility of lengthy evaluations resulting in overdiagnosis and overtreatment. Our overarching goal is for this CFS to help clinicians in their daily clinical practice as they seek to optimize their diagnostic skill and patient care.

A call to action: next steps to advance diagnosis education in the health professions

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.

Managing the tension between caring and charting: Labor and delivery nurses' experiences of the electronic health record

Over a decade following the nationwide push to implement electronic health records (EHRs), the focus has shifted to addressing the cognitive burden associated with their use. Most research and discourse about the EHR's impact on clinicians' cognitive work has focused on physicians rather than on nursing-specific issues. Labor and delivery nurses may encounter unique challenges when using EHRs because they also interact with an electronic fetal monitoring system, continuously managing and synthesizing both maternal and fetal data. This grounded theory study explored labor and delivery nurses' perceptions of the EHR's impact on their cognitive work. Data were individual interviews and participant observations with twenty-one nurses from two labor and delivery units in the western U.S. and were analyzed using dimensional analysis. Nurses managed the tension between caring and charting using various strategies to integrate the EHR into their dynamic, high-acuity, specialty practice environment while using EHRs that were not designed for perinatal patients. Use of the EHR and associated technologies disrupted nurses' ability to locate and synthesize information, maintain an overview of the patient's status, and connect with patients and families. Individual-, group-, and environmental-level factors facilitated or constrained nurses' integration of the EHR. These findings represent critical safety failures requiring comprehensive changes to EHR designs and better processes for responding to end-user experiences. More research is needed to develop EHRs that support the dynamic and relationship-based nature of nurses' work and to align with specialty practice environments.

The variability in how physicians think: a casebased diagnostic simulation exercise

OBJECTIVES

Little is known about how physician diagnostic thinking unfolds over time when evaluating patients. We designed a case-based simulation to understand how physicians reason, create differential diagnoses, and employ strategies to achieve a correct diagnosis.

METHODS

Between June 2017 and August 2018, hospital medicine physicians at two academic medical centers were presented a standardized case of a patient presenting with chest pain who was ultimately diagnosed with herpes zoster using an interview format. Case information was presented in predetermined aliquots where participants were then asked to think-aloud, describing their thoughts and differential diagnoses given the data available. At the conclusion of the interview, participants were asked questions about their diagnostic process. Interviews were recorded, transcribed, and content analysis was conducted to identify key themes related to the diagnostic thinking process.

RESULTS

Sixteen hospital medicine physicians (nine men, seven women) participated in interviews and four obtained the correct final diagnosis (one man, three women). Participants had an average of nine years of experience. Overall, substantial heterogeneity in both the differential diagnoses and clinical reasoning among participants was observed. Those achieving the correct diagnosis utilized systems-based or anatomic approaches when forming their initial differential diagnoses, rather than focusing on life-threatening diagnoses alone. Evidence of cognitive bias was common; those with the correct diagnosis more often applied debiasing strategies than those with the incorrect final diagnosis.

CONCLUSIONS

Heterogeneity in diagnostic evaluation appears to be common and may indicate faulty data processing. Structured approaches and debiasing strategies appear helpful in promoting diagnostic accuracy.

Clinical Reasoning in Forensic Psychiatry: Concepts, Processes, and Pitfalls

Forensic psychiatrists are often sought by the court of law to provide professional opinion on specific legal matters that have a major impact on the evaluee and possibly society at large. The quality of that opinion and recommendations rely on the quality of the analysis from the assessment results conducted by the psychiatrist. However, the definition and scope of a forensic psychiatric analysis is not clear. While existing literature on forensic psychiatric analysis generally includes organizing information, identifying relevant details, and formulating a set of forensic psychiatric opinions as components, there is no explicit and unified definition of these terms and process. This lack of clarity and guidelines may hinder forensic psychiatry from achieving its goal of providing objective information to the court or other relevant parties. Forensic psychiatric analysis exhibits numerous parallels to clinical reasoning in other fields of medicine. Therefore, this review aims to elaborate forensic psychiatric analysis through the lens of clinical reasoning, which has been developed by incorporating advances in cognitive sciences. We describe forensic psychiatric analysis through three prominent clinical reasoning theories: hypothetico-deductive model, illness script theory, and dual process theory. We expand those theories to elucidate how forensic psychiatrists use clinical reasoning not only to diagnose mental disorders, but also to determine mental capacities as requested by law. Cognitive biases are also described as potential threat to the accuracy of the assessment and analysis. Additionally, situated cognition theory helps elucidate how contextual factors influence risk of errors. Understanding the processes involved in forensic psychiatric analysis and their pitfalls can assist forensic psychiatrists to be aware of and try to mitigate their bias. Debiasing strategies that have been implemented in other fields of medicine to mitigate errors in clinical reasoning can be adapted for forensic psychiatry. This may also shape the training program of general psychiatrists and forensic psychiatrists alike.

Increasing Physician Reporting of Diagnostic Learning Opportunities

BACKGROUND

An estimated 10% of Americans experience a diagnostic error annually, yet little is known about pediatric diagnostic errors. Physician reporting is a promising method for identifying diagnostic errors. However, our pediatric hospital medicine (PHM) division had only 1 diagnostic-related safety report in the preceding 4 years. We aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months.

METHODS

Our improvement team used the Model for Improvement, targeting the PHM service. To promote a safe reporting culture, we used the term diagnostic learning opportunity (DLO) rather than diagnostic error, defined as a "potential opportunity to make a better or more timely diagnosis." We developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. The outcome measure, the number of DLO reports per 100 patient admissions, was tracked on an annotated control chart to assess the effect of our interventions over time. We evaluated DLOs using a formal 2-reviewer process.

RESULTS

Over the course of 13 weeks, there was an increase in the number of reports filed from 0 to 1.6 per 100 patient admissions, which met special cause variation, and was subsequently sustained. Most events (66%) were true diagnostic errors and were found to be multifactorial after formal review.

CONCLUSIONS

We used quality improvement methodology, focusing on psychological safety, to increase physician reporting of DLOs. This growing data set has generated nuanced learnings that will guide future improvement work.

Referral communication for pediatric intensive care unit admission and the diagnosis of critically ill children: A pilot ethnography

PURPOSE

The effect of communication between referring and accepting clinicians during patient transitions to the pediatric intensive care unit (PICU) on diagnostic quality is largely unknown. This pilot study aims to determine the feasibility of using focused ethnography to understand the relationship between referral communication and the diagnostic process for critically ill children.

MATERIALS AND METHODS

We conducted focused ethnography in an academic tertiary referral PICU by directly observing the referral and admission of 3 non-electively admitted children 0-17 years old. We also conducted 21 semi-structured interviews of their parents and admitting PICU staff (intensivists, fellows/residents, medical students, nurses, and respiratory therapists) and reviewed their medical records post-discharge.

RESULTS

Performing focused ethnography in a busy PICU is feasible. We identified three areas for additional exploration: (1) how information transfer affects the PICU diagnostic process; (2) how uncertainty in patient assessment affects the decision to transfer to the PICU; and (3) how the PICU team's expectations are influenced by referral communication.

CONCLUSIONS

Focused ethnography in the PICU is feasible to investigate relationships between clinician referral communication and the diagnostic process for critically ill children.

Focused ethnography: a new tool to study diagnostic errors?

While much attention has been given to quantifying errors in diagnosis, how best to study the process of diagnosis is less clear. Focused ethnography as a methodology is particularly valuable for studying healthcare processes because it examines specific questions, situations or problems among a smaller group of individuals. In this paper, we review this approach and illustrate how we applied it to study diagnostic errors in hospitalized patients.

Understanding the roles of three academic communities in a prospective learning health ecosystem for diagnostic excellence

Inaccurate, untimely, and miscommunicated medical diagnoses represent a wicked problem requiring comprehensive and coordinated approaches, such as those demonstrated in the characteristics of learning health systems (LHSs). To appreciate a vision for how LHS methods can optimize processes and outcomes in medical diagnosis (diagnostic excellence), we interviewed 32 individuals with relevant expertise: 18 who have studied diagnostic processes using traditional behavioral science and health services research methods, six focused on machine learning (ML) and artificial intelligence (AI) approaches, and eight multidisciplinary researchers experienced in advocating for and incorporating LHS methods, ie, scalable continuous learning in health care. We report on barriers and facilitators, identified by these subjects, to applying their methods toward optimizing medical diagnosis. We then employ their insights to envision the emergence of a learning ecosystem that leverages the tools of each of the three research groups to advance diagnostic excellence. We found that these communities represent a natural fit forward, in which together, they can better measure diagnostic processes and close the loop of putting insights into practice. Members of the three academic communities will need to network and bring in additional stakeholders before they can design and implement the necessary infrastructure that would support ongoing learning of diagnostic processes at an economy of scale and scope.

Using Voogle to Search Within Patient Records in the VA Corporate Data Warehouse

The VA has developed a tool to search its Corporate Data Warehouse, which provides easy access to patient data for better clinical decision making.

Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process

Background Diagnosis requires that clinicians communicate and share patient information in an efficient manner. Advances in electronic health records (EHRs) and health information technologies have created both challenges and opportunities for such communication. Methods We conducted a multi-method, focused ethnographic study of physicians on general medicine inpatient units in two teaching hospitals. Physician teams were observed during and after morning rounds to understand workflow, data sharing and communication during diagnosis. To validate findings, interviews and focus groups were conducted with physicians. Field notes and interview/focus group transcripts were reviewed and themes identified using content analysis. Results Existing communication technologies and EHR-based data sharing processes were perceived as barriers to diagnosis. In particular, reliance on paging systems and lack of face-to-face communication among clinicians created obstacles to sustained thinking and discussion of diagnostic decision-making. Further, the EHR created data overload and data fragmentation, making integration for diagnosis difficult. To improve diagnosis, physicians recommended replacing pagers with two-way communication devices, restructuring the EHR to facilitate access to key information and improving training on EHR systems. Conclusions As advances in health information technology evolve, challenges in the way clinicians share information during the diagnostic process will rise. To improve diagnosis, changes to both the technology and the way in which we use it may be necessary.

How Medical Error Shapes Physicians' Perceptions of Learning: An Exploratory Study

PURPOSE

Error is inevitable in medicine, given its inherent uncertainty and complexity. Errors can teach powerful lessons; however, because of physicians' self-imposed silence and the intricacies of responsibility and blame, learning from medical error has been underexplored. The purpose of this study was to understand how physicians perceived learning from medical errors by exploring the tension between responsibility and blame and factors that affected physicians' learning.

METHOD

Nineteen physicians participated in semistructured interviews, conducted in 2016-2017 at Western University in Canada, that probed their experiences in learning from medical errors. Data collection and analysis were conducted iteratively, with themes identified through constant comparative analysis.

RESULTS

Participants felt personal responsibility and blame for their errors. Residency produced particularly salient memories of errors. Participants identified interconnecting cultural factors (normalizing error, peer support and mentorship, formal rounds) and individual factors (emotional response, confidence and experience), which either helped or hindered their perceived learning.

CONCLUSIONS

Learning from medical error requires navigation through blame and responsibility. The keen responsibility felt by physicians must be acknowledged when enacting a system-based approach to medical error. Adopting a learning culture perspective suggests opportunities to enable and disable features of the learning environment to optimize learning from error as residents learn to become the most responsible physician for all outcomes. A better understanding of the factors that shape learning from error can help make the transition from error to learning more explicit, thereby increasing the opportunity to learn and teach from errors that permeate the practice of medicine.