Use of a Modified Fishbone Diagram to Analyze Diagnostic Errors in Emergency Physicians.

INTRODUCTION: Reilly et al. described a structured approach to the analysis of diagnostic errors by using a novel modifi ed fi shbone diagram. The application of this tool in emergency medicine had not previously been reported. The objective of this study is to use the modified fishbone diagram analysis method in examining the causes of common diagnostic errors committed by emergency physicians and the circumstances associating errors in cognitive processes. METHODS: Sixty-one cases of diagnostic errors involving ten board-certified emergency physicians (EPs) were identifi ed through a peer review process. Using a qualitative study approach, in-depth semi structured interviews with EPs was conducted. All interview audiotapes were transcribed verbatim. Content analysis was performed on all textual data to identify the factors underlying errors using the modified fishbone diagram. RESULTS: In 61 cases, 165 diagnostic errors were identified (2.7 per case). The underlying contributions to errors fell into 7 categories: cognitive process (54/61, 89%), specific presentation (32/61, 52%), clinical data gathering (24/61, 39%), organization issues (12/61, 20%), affective factors (9/61, 15%), context of care (9/61, 15%), and communication (5/61, 8%). Of these cognitive errors were the most common. However, only six cases occurred in isolation (6/54, 11%), with the remaining 48 cases (48/54, 89%) occurring with other types of errors, the most common being specific presentation (28/54, 52%) and clinical data gathering (24/54, 44%). CONCLUSIONS: The modified fishbone diagram is a useful tool to identify various categories of errors on diagnostic process in emergency department (ED). These fi ndings provide a basis on which to build a framework for teaching EPs how to avoid misdiagnoses in the ED setting.

Ultrasound phantoms made of gelatin covered with hydrocolloid skin dressing.

BACKGROUND: Ultrasound-guided invasive procedures, such as central venous catheter insertion, soft-tissue abscess drainage, and foreign-body removal are essential competencies for Emergency Physicians. Such competencies can be trained using ultrasound phantoms. OBJECTIVE: Our aim is to describe ultrasound phantoms that are easily made, inexpensive, reusable, and can withstand multiple punctures. METHODS: Previously recommended gelatin-only ultrasound phantoms have inadequate surface tension resulting in surface disruption, and cannot tolerate multiple punctures when simulating cyst drainage. RESULTS: By covering the gelatin phantom with a hydrocolloid skin dressing, we are able to minimize physical surface disruption (by transducer or needles) and might reduce biological breakdown due to bacterial propagation. CONCLUSIONS: The elements required to construct homemade reusable ultrasound phantoms are inexpensive and can be easily obtained.