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Cox C, Hatfield T, Willars J, Fritz Z. Identifying Facilitators and Inhibitors of Shared Understanding: An Ethnography of Diagnosis Communication in Acute Medical Settings. Health Expect 2024; 27:e14180. [PMID: 39180375 PMCID: PMC11344224 DOI: 10.1111/hex.14180] [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: 04/08/2024] [Revised: 07/10/2024] [Accepted: 07/31/2024] [Indexed: 08/26/2024] Open
Abstract
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.
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Affiliation(s)
- Caitríona Cox
- The Healthcare Improvement Studies InstituteCambridgeUK
| | - Thea Hatfield
- The Healthcare Improvement Studies InstituteCambridgeUK
| | - Janet Willars
- The Healthcare Improvement Studies InstituteCambridgeUK
| | - Zoë Fritz
- The Healthcare Improvement Studies InstituteCambridgeUK
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2
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Gupta AB, Greene MT, Fowler KE, Chopra VI. Associations Between Hospitalist Shift Busyness, Diagnostic Confidence, and Resource Utilization: A Pilot Study. J Patient Saf 2023; 19:447-452. [PMID: 37729642 PMCID: PMC10516505 DOI: 10.1097/pts.0000000000001157] [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: 09/22/2023]
Abstract
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.
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3
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Sloane JF, Donkin C, Newell BR, Singh H, Meyer AND. Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda. J Gen Intern Med 2023; 38:1526-1531. [PMID: 36697925 PMCID: PMC10160308 DOI: 10.1007/s11606-022-08019-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/29/2022] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Jennifer F Sloane
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
- School of Psychology, University of New South Wales Sydney, Kensington, Australia.
| | - Chris Donkin
- School of Psychology, University of New South Wales Sydney, Kensington, Australia
- Ludwig Maximilian University of Munich, Munich, Germany
| | - Ben R Newell
- School of Psychology, University of New South Wales Sydney, Kensington, Australia
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ashley N D Meyer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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4
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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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5
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Kaplan HM, Birnbaum JF, Kulkarni PA. Pursuit of "endpoint diagnoses" as a cognitive forcing strategy to avoid premature diagnostic closure. Diagnosis (Berl) 2022; 9:421-429. [PMID: 35942949 DOI: 10.1515/dx-2022-0013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/17/2022] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Holland M Kaplan
- Department of Medicine, Section of General Internal Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Jacqueline F Birnbaum
- Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Prathit A Kulkarni
- Medical Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Department of Medicine, Section of Infectious Disease, Baylor College of Medicine, Houston, TX, USA
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6
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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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7
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Wisner K, Chesla CA, Spetz J, Lyndon A. Managing the tension between caring and charting: Labor and delivery nurses' experiences of the electronic health record. Res Nurs Health 2021; 44:822-832. [PMID: 34402080 DOI: 10.1002/nur.22177] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 06/13/2021] [Accepted: 07/31/2021] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Kirsten Wisner
- Department of Family Health Care Nursing, University of California San Francisco, San Francisco, California, USA.,Salinas Valley Memorial Healthcare System, Salinas, California, USA
| | - Catherine A Chesla
- Department of Family Health Care Nursing, University of California San Francisco, San Francisco, California, USA
| | - Joanne Spetz
- Brenda and Jeffrey L. Kang Presidential Chair in Healthcare Finance, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Audrey Lyndon
- Rory Myers College of Nursing, New York University, New York, New York, USA
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Gupta A, Quinn M, Saint S, Lewis R, Fowler KE, Winter S, Chopra V. The variability in how physicians think: a casebased diagnostic simulation exercise. Diagnosis (Berl) 2021; 8:167-175. [PMID: 32697753 PMCID: PMC7855370 DOI: 10.1515/dx-2020-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/28/2020] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- Ashwin Gupta
- VA Ann Arbor Healthcare System Medicine Service, Ann Arbor, MI, USA
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Martha Quinn
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Sanjay Saint
- VA Ann Arbor Healthcare System Medicine Service, Ann Arbor, MI, USA
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Richard Lewis
- Department of Psychology, School of Language, Science, and Arts, University of Michigan, Ann Arbor, MI, USA
| | - Karen E Fowler
- VA Ann Arbor Healthcare System Medicine Service, Ann Arbor, MI, USA
| | - Suzanne Winter
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Vineet Chopra
- VA Ann Arbor Healthcare System Medicine Service, Ann Arbor, MI, USA
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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Raharjanti NW, Wiguna T, Purwadianto A, Soemantri D, Bardosono S, Poerwandari EK, Mahajudin MS, Ramadianto AS, Alfonso CA, Findyartini A, Nugrahadi NR, Lazuardi MQ, Subroto PAM, Saroso OJDA, Levania MK. Clinical Reasoning in Forensic Psychiatry: Concepts, Processes, and Pitfalls. Front Psychiatry 2021; 12:691377. [PMID: 34421677 PMCID: PMC8374734 DOI: 10.3389/fpsyt.2021.691377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/09/2021] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Natalia Widiasih Raharjanti
- Doctoral Program in Medical Sciences, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia.,Department of Psychiatry, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Tjhin Wiguna
- Department of Psychiatry, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Agus Purwadianto
- Department of Forensic and Medicolegal, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Diantha Soemantri
- Department of Medical Education, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Saptawati Bardosono
- Department of Nutrition, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | | | | | - Adhitya Sigit Ramadianto
- Department of Psychiatry, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - César A Alfonso
- Doctoral Program in Medical Sciences, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia.,Department of Psychiatry, Columbia University, New York, NY, United States
| | - Ardi Findyartini
- Department of Medical Education, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Nadia Rahmadiani Nugrahadi
- Department of Psychiatry, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Muhammad Qolby Lazuardi
- Department of Psychiatry, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Priscilla Aya Maheswari Subroto
- Department of Psychiatry, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | | | - Monika Kristi Levania
- Department of Psychiatry, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
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Marshall TL, Ipsaro AJ, Le M, Sump C, Darrell H, Mapes KG, Bick J, Ferris SA, Bolser BS, Simmons JM, Hagedorn PA, Brady PW. Increasing Physician Reporting of Diagnostic Learning Opportunities. Pediatrics 2021; 147:peds.2019-2400. [PMID: 33268395 DOI: 10.1542/peds.2019-2400] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Trisha L Marshall
- Divisions of Hospital Medicine and .,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | | | - Matthew Le
- Pediatric Residency Training Program and
| | | | | | | | | | | | | | - Jeffrey M Simmons
- Divisions of Hospital Medicine and.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | - Philip A Hagedorn
- Divisions of Hospital Medicine and.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Information Services and.,Biomedical Informatics and
| | - Patrick W Brady
- Divisions of Hospital Medicine and.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
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11
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Cifra CL, Dukes KC, Ayres BS, Calomino KA, Herwaldt LA, Singh H, Reisinger HS. Referral communication for pediatric intensive care unit admission and the diagnosis of critically ill children: A pilot ethnography. J Crit Care 2020; 63:246-249. [PMID: 32980235 DOI: 10.1016/j.jcrc.2020.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/27/2020] [Accepted: 09/12/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Christina L Cifra
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, 200 Hawkins Dr 8600-M JCP, Iowa City, IA 52242, USA.
| | - Kimberly C Dukes
- Institute for Clinical and Translational Science, University of Iowa 200 Hawkins Dr, Iowa City, IA 52242, USA; Iowa City Veterans Affairs Health Care System, 601 US-6 W Suite 42-1 VAMC, Iowa City, IA 52246, USA.
| | - Brennan S Ayres
- Department of Industrial and Systems Engineering, University of Iowa College of Engineering 3100 Seamans Center for the Engineering Arts and Sciences, Iowa City, IA 52242, USA; Touro College of Osteopathic Medicine (present address), 230 W 125(th) St, New York, NY 10027, USA
| | - Kelsey A Calomino
- University of Iowa College of Nursing, 50 Newton Rd, Iowa City, IA 52242, USA.
| | - Loreen A Herwaldt
- Department of Internal Medicine, University of Iowa Carver College of Medicine 200 Hawkins Dr, Iowa City, IA 52242, USA; Department of Epidemiology, University of Iowa College of Public Health 145 N Riverside Dr, Iowa City, IA 52242, USA.
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey eterans Affairs Medical Center and Baylor College of Medicine, 2002 Holcombe Blvd, Houston, TX 77030, USA.
| | - Heather Schacht Reisinger
- Institute for Clinical and Translational Science, University of Iowa 200 Hawkins Dr, Iowa City, IA 52242, USA; Department of Internal Medicine, University of Iowa Carver College of Medicine 200 Hawkins Dr, Iowa City, IA 52242, USA; Iowa City Veterans Affairs Health Care System, 601 US-6 W Suite 42-1 VAMC, Iowa City, IA 52246, USA.
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12
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Chopra V. Focused ethnography: a new tool to study diagnostic errors? Diagnosis (Berl) 2020; 7:211-214. [DOI: 10.1515/dx-2020-0009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/09/2020] [Indexed: 11/15/2022]
Abstract
Abstract
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.
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Affiliation(s)
- Vineet Chopra
- The Division of Hospital Medicine, Department of Internal Medicine , University of Michigan Health System , 2800 Plymouth Road, Building 16 #432W , Ann Arbor, MI 48104 , USA
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Satterfield K, Rubin JC, Yang D, Friedman CP. Understanding the roles of three academic communities in a prospective learning health ecosystem for diagnostic excellence. Learn Health Syst 2019; 4:e210204. [PMID: 31989032 PMCID: PMC6971119 DOI: 10.1002/lrh2.10204] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/19/2019] [Accepted: 09/25/2019] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Katherine Satterfield
- Department of Learning Health SciencesUniversity of Michigan Medical SchoolAnn ArborMichigan
| | - Joshua C. Rubin
- Department of Learning Health SciencesUniversity of Michigan Medical SchoolAnn ArborMichigan
| | - Daniel Yang
- The Gordon and Betty Moore FoundationPalo AltoCalifornia
| | - Charles P. Friedman
- Department of Learning Health SciencesUniversity of Michigan Medical SchoolAnn ArborMichigan
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14
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Turano A, Eibling D. Using Voogle to Search Within Patient Records in the VA Corporate Data Warehouse. Fed Pract 2019; 36:518-523. [PMID: 31892775 PMCID: PMC6913608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The VA has developed a tool to search its Corporate Data Warehouse, which provides easy access to patient data for better clinical decision making.
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Affiliation(s)
- Augie Turano
- is Director Veterans Informatics and Computing Infrastructure in the VA Office of Information and Technology, and is an Otolaryngologist in the Surgery Service at VA Pittsburgh Healthcare System in Pennsylvania. Both Augie Turano and David Eibling hold faculty appointments and teach at the University of Pittsburgh
| | - David Eibling
- is Director Veterans Informatics and Computing Infrastructure in the VA Office of Information and Technology, and is an Otolaryngologist in the Surgery Service at VA Pittsburgh Healthcare System in Pennsylvania. Both Augie Turano and David Eibling hold faculty appointments and teach at the University of Pittsburgh
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Quinn M, Forman J, Harrod M, Winter S, Fowler KE, Krein SL, Gupta A, Saint S, Singh H, Chopra V. Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process. Diagnosis (Berl) 2019; 6:241-248. [PMID: 30485175 PMCID: PMC6691503 DOI: 10.1515/dx-2018-0036] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/19/2018] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Martha Quinn
- School of Public Health, University of Michigan, Ann Arbor, MI
| | - Jane Forman
- VA Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI
| | - Molly Harrod
- VA Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI
| | - Suzanne Winter
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Karen E. Fowler
- VA Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI
| | - Sarah L. Krein
- VA Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Ashwin Gupta
- VA Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Sanjay Saint
- VA Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Hardeep Singh
- Michael E. DeBakey VA Medical Center/Baylor College of Medicine, Houston, TX
| | - Vineet Chopra
- VA Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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Shepherd L, LaDonna KA, Cristancho SM, Chahine S. How Medical Error Shapes Physicians' Perceptions of Learning: An Exploratory Study. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:1157-1163. [PMID: 30973366 DOI: 10.1097/acm.0000000000002752] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Lisa Shepherd
- L. Shepherd is associate professor, Department of Medicine, Division of Emergency Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; ORCID: https://orcid.org/0000-0001-9551-4546. K.A. LaDonna is assistant professor, Departments of Innovation in Medical Education and Medicine, University of Ottawa, Ottawa, Ontario, Canada. S.M. Cristancho is assistant professor, Department of Surgery and Faculty of Education, and scientist, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. S. Chahine is assistant professor, Department of Medicine and Faculty of Education, and scientist, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; ORCID: https://orcid.org/0000-0003-0488-773X
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Chopra V, Saint S. In Reply to "Diving Into Diagnostic Uncertainty: Strategies to Mitigate Cognitive Load. In Reference to: 'Focused Ethnography of Diagnosis in Academic Medical Centers'". J Hosp Med 2018; 13:805. [PMID: 30484783 DOI: 10.12788/jhm.3078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Vineet Chopra
- Division of Hospital Medicine and the VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, Michigan, USA.
| | - Sanjay Saint
- Division of Hospital Medicine and the VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, Michigan, USA
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