Writing Case Reports Can Improve Seven Components in Clinical Reasoning

Case reports provide scientific knowledge and opportunities for new clinical research. However, it is estimated that less than 5% of cases presented by Japanese generalists at academic conferences are published due to various barriers such as the complex process of writing articles, conducting literature searches, the significant time required, the reluctance to write in English, and the challenge of selecting appropriate journals for publication. Therefore, the purpose of this opinion paper is to provide clinicians with practical tips for writing case reports that promote diagnostic excellence. In recent years, clinical practitioners have been striving for diagnostic excellence and optimal methods to accurately and comprehensively understand the patient's condition. To write a case report, it is essential to be mindful of the elements of diagnostic excellence and consider the quality of the diagnostic reasoning process. We (the authors) are seven academic generalists who are members of the Japanese Society of Hospital General Medicine (JSHGM) - Junior Doctors Association, with a median of 7 years after graduation and extensive experience publishing case reports in international peer-reviewed journals. We conducted a narrative review and discussed ways to write case reports to promote diagnostic excellence, leveraging our unique perspectives as academic generalists. Our review did not identify any reports addressing the critical points in writing case reports that embody diagnostic excellence. Therefore, this report proposes a methodology that describes the process involved in writing diagnostic excellence-promoting case reports and provides an overview of the lessons learned. Based on our review and discussion, we explain the essential points for promoting diagnostic excellence through case reports categorized into seven components of clinical reasoning. These strategies are useful in daily clinical practice and instrumental in promoting diagnostic excellence through case reports.

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy

Solving diagnostic errors is difficult and progress on preventing those errors has been slow since the 2015 National Academy of Medicine report. There are several methods used to improve diagnostic and other errors including voluntary reporting; malpractice claims; patient complaints; physician surveys, random quality reviews and audits, and peer review data which usually evaluates single cases and not the systems that allowed the error. Additionally, manual review of charts is often labor intensive and reviewer dependent. In 2010 we developed an e-Autopsy/e-Biopsy (eA/eB) methodology to aggregate cases with quality/safety/diagnostic issues, focusing on a specific population of patients and conditions. By performing a hybrid review process (cases are first filtered using administrative data followed by standardized manual chart reviews) we can efficiently identify patterns of medical and diagnostic error leading to opportunities for system improvements that have improved care for future patients. We present a detailed methodology for eA/eB studies and describe results from three successful studies on different diagnoses (ectopic pregnancy, abdominal aortic aneurysms, and advanced colon cancer) that illustrate our eA/eB process and how it reveals insights into creating systems that reduce diagnostic and other errors. The eA/eB process is innovative and transferable to other healthcare organizations and settings to identify trends in diagnostic error and other quality issues resulting in improved systems of care.

Creating a Learning Health System for Improving Diagnostic Safety: Pragmatic Insights from US Health Care Organizations

OBJECTIVE

To identify challenges and pragmatic strategies for improving diagnostic safety at an organizational level using concepts from learning health systems METHODS: We interviewed 32 safety leaders across the USA on how their organizations approach diagnostic safety. Participants were recruited through email and represented geographically diverse academic and non-academic settings. The interview included questions on culture of reporting and learning from diagnostic errors; data gathering and analysis activities; diagnostic training and educational activities; and engagement of clinical leadership, staff, patients, and families in diagnostic safety activities. We conducted an inductive content analysis of interview transcripts and two reviewers coded all data.

RESULTS

Of 32 participants, 12 reported having a specific program to address diagnostic errors. Multiple barriers to implement diagnostic safety activities emerged: serious concerns about psychological safety associated with diagnostic error; lack of infrastructure for measurement, monitoring, and improvement activities related to diagnosis; lack of leadership investment, which was often diverted to competing priorities related to publicly reported measures or other incentives; and lack of dedicated teams to work on diagnostic safety. Participants provided several strategies to overcome barriers including adapting trigger tools to identify safety events, engaging patients in diagnostic safety, and appointing dedicated diagnostic safety champions.

CONCLUSIONS

Several foundational building blocks related to learning health systems could inform organizational efforts to reduce diagnostic error. Promoting an organizational culture specific to diagnostic safety, using science and informatics to improve measurement and analysis, leadership incentives to build institutional capacity to address diagnostic errors, and patient engagement in diagnostic safety activities can enable progress.

Operational measurement of diagnostic safety: state of the science

Reducing the incidence of diagnostic errors is increasingly a priority for government, professional, and philanthropic organizations. Several obstacles to measurement of diagnostic safety have hampered progress toward this goal. Although a coordinated national strategy to measure diagnostic safety remains an aspirational goal, recent research has yielded practical guidance for healthcare organizations to start using measurement to enhance diagnostic safety. This paper, concurrently published as an Issue Brief by the Agency for Healthcare Research and Quality, issues a "call to action" for healthcare organizations to begin measurement efforts using data sources currently available to them. Our aims are to outline the state of the science and provide practical recommendations for organizations to start identifying and learning from diagnostic errors. Whether by strategically leveraging current resources or building additional capacity for data gathering, nearly all organizations can begin their journeys to measure and reduce preventable diagnostic harm.