An organisational approach to improving diagnostic safety.

Diagnostic error affects up to 10% of clinical encounters and is a major contributing factor to 1 in 100 hospital deaths. Most errors involve cognitive failures from clinicians but organisational shortcomings also act as predisposing factors. There has been considerable focus on profiling causes for incorrect reasoning intrinsic to individual clinicians and identifying strategies that may help to prevent such errors. Much less focus has been given to what healthcare organisations can do to improve diagnostic safety. A framework modelled on the US Safer Diagnosis approach and adapted for the Australian context is proposed, which includes practical strategies actionable within individual clinical departments. Organisations adopting this framework could become centres of diagnostic excellence. This framework could act as a starting point for formulating standards of diagnostic performance that may be considered as part of accreditation programs for hospitals and other healthcare organisations.

Communication of Diagnostic Uncertainty in Primary Care and Its Impact on Patient Experience: an Integrative Systematic Review.

BACKGROUND: Diagnostic uncertainty is a pervasive issue in primary care where patients often present with non-specific symptoms early in the disease process. Knowledge about how clinicians communicate diagnostic uncertainty to patients is crucial to prevent associated diagnostic errors. Yet, in-depth research on the interpersonal communication of diagnostic uncertainty has been limited. We conducted an integrative systematic literature review (PROSPERO CRD42020197624, unfunded) to investigate how primary care doctors communicate diagnostic uncertainty in interactions with patients and how patients experience their care in the face of uncertainty. METHODS: We searched MEDLINE, PsycINFO, and Linguistics and Language Behaviour Abstracts (LLBA) from inception to December 2021 for MeSH and keywords related to 'communication', 'diagnosis', 'uncertainty' and 'primary care' environments and stakeholders (patients and doctors), and conducted additional handsearching. We included empirical primary care studies published in English on spoken communication of diagnostic uncertainty by doctors to patients. We assessed risk of bias with the QATSDD quality assessment tool and conducted thematic and content analysis to synthesise the results. RESULTS: Inclusion criteria were met for 19 out of 1281 studies. Doctors used two main communication strategies to manage diagnostic uncertainty: (1) patient-centred communication strategies (e.g. use of empathy), and (2) diagnostic reasoning strategies (e.g. excluding serious diagnoses). Linguistically, diagnostic uncertainty was either disclosed explicitly or implicitly through diverse lexical and syntactical constructions, or not communicated (omission). Patients' experiences of care in response to the diverse communicative and linguistic strategies were mixed. Patient-centred approaches were generally regarded positively by patients. DISCUSSION: Despite a small number of included studies, this is the first review to systematically catalogue the diverse communication and linguistic strategies to express diagnostic uncertainty in primary care. Health professionals should be aware of the diverse strategies used to express diagnostic uncertainty in practice and the value of combining patient-centred approaches with diagnostic reasoning strategies.

Sports-related ocular injuries at a tertiary eye hospital in Australia: A 5-year retrospective descriptive study.

OBJECTIVE: To describe the demographics and outcomes of sports-related ocular injuries in an Australian tertiary eye hospital setting. METHODS: Retrospective descriptive study from the Royal Victorian Eye and Ear Hospital from 2015 to 2020. Patient demographics, diagnosis and injury causation were recorded from baseline and follow-up. Outcomes included visual acuity (VA), intraocular pressure (IOP), ocular injury diagnosis, investigations and management performed. RESULTS: A total of 1793 individuals (mean age 28.67 ± 15.65 years; 80.42% males and 19.58% females) presented with sports-related ocular trauma. The top three injury-causing sports were soccer (n = 327, 18.24%), Australian rules football (AFL) (n = 306, 17.07%) and basketball (n = 215, 11.99%). The top injury mechanisms were projectile (n = 976, 54.43%) and incidental body contact (n = 506, 28.22%). The most frequent diagnosis was traumatic hyphaema (n = 725). Best documented VA was ≥6/12 at baseline in 84.8% and at follow-up in 95.0% of cases. The greatest risk of globe rupture/penetration was associated with martial arts (odds ratio [OR] 16.22); orbital blow-out fracture with skiing (OR 14.42); and hyphaema with squash (OR 4.18): P < 0.05 for all. Topical steroids were the most common treatment (n = 693, 38.7%). Computed tomography orbits/facial bones were the most common investigation (n = 184, 10.3%). The mean IOP was 16.1 mmHg; 103 (5.7%) cases required topical anti-ocular hypertensives. Twenty-six individuals (1.45%) required surgery with AFL contributing the most surgical cases (n = 5, 19.23%). CONCLUSION: The top three ocular injury causing sports were soccer, AFL and basketball. The most frequent injury was traumatic hyphaema. Projectiles posed the greatest risk.

Diagnostic statements: a linguistic analysis of how clinicians communicate diagnosis.

OBJECTIVES: To investigate from a linguistic perspective how clinicians deliver diagnosis to patients, and how these statements relate to diagnostic accuracy. METHODS: To identify temporal and discursive features in diagnostic statements, we analysed 16 video-recorded interactions collected during a practice high-stakes exam for internationally trained clinicians (25% female, n=4) to gain accreditation to practice in Australia. We recorded time spent on history-taking, examination, diagnosis and management. We extracted and deductively analysed types of diagnostic statements informed by literature. RESULTS: Half of the participants arrived at the correct diagnosis, while the other half misdiagnosed the patient. On average, clinicians who made a diagnostic error took 30 s less in history-taking and 30 s more in providing diagnosis than clinicians with correct diagnosis. The majority of diagnostic statements were evidentialised (describing specific observations (n=24) or alluding to diagnostic processes (n=7)), personal knowledge or judgement (n=8), generalisations (n=6) and assertions (n=4). Clinicians who misdiagnosed provided more specific observations (n=14) than those who diagnosed correctly (n=9). CONCLUSIONS: Interactions where there is a diagnostic error, had shorter history-taking periods, longer diagnostic statements and featured more evidence. Time spent on history-taking and diagnosis, and use of evidentialised diagnostic statements may be indicators for diagnostic accuracy.

'More than words' - Interpersonal communication, cognitive bias and diagnostic errors.

During the diagnostic process, clinicians may make assumptions, prematurely judge or diagnose patients based on their appearance, their speech or how they are portrayed by other clinicians. Such judgements can be a major source of diagnostic error and are often linked to unconscious cognitive biases - faulty quick-fire thinking patterns that impact clinical reasoning. Patient safety is profoundly influenced by cognitive bias and language, i.e. how information is presented or gathered, and then synthesised by clinicians to form and communicate diagnostic decisions. Here, we discuss the intricate links between interpersonal communication, cognitive bias, and diagnostic error from a patient's, a linguist's and clinician's perspective. We propose that through patient engagement and applied health communication research, we can enhance our understanding of how the interplay of communication behaviours, biases and errors can impact upon the patient experience and diagnostic error. In doing so, we provide new avenues for collaborative diagnostic error research striving towards healthcare improvements and safer diagnosis.

Developing critical thinking skills for delivering optimal care.

Healthcare systems across the world are challenged with problems of misdiagnosis, non-beneficial care, unwarranted practice variation and inefficient or unsafe practice. In countering these shortcomings, clinicians must be able to think critically, interpret and assimilate new knowledge, deal with uncertainty and change behaviour in response to compelling new evidence. Three critical thinking skills underpin effective care: clinical reasoning, evidence-informed decision-making and systems thinking. It is important to define these skills explicitly, explain their rationales, describe methods of instruction and provide examples of optimal application. Educational methods for developing and refining these skills must be embedded within all levels of clinician training and continuing professional development.

Implementing a pandemic roster in a specialty emergency department: Challenges and benefits.

OBJECTIVE: To create a roster that eliminated unnecessary cross-staff exposure to ensure the hospital had sufficient staff to run the ED in the event that a group of staff are affected by COVID-19. This roster was aimed at providing staff with 'manageable shift lengths, down-time between shifts, regular breaks and access to refreshments' as dictated by the Victorian Department of Health and Human Services. METHODS: Creating six fixed teams in our ED. Teams work blocks of three consecutive days of 12 h shifts, each block alternates between day and night shifts. RESULTS: We managed to completely eliminate unnecessary crossover of staff thus reducing risk of having a large part of our workforce incapacitated should any member be affected by COVID. CONCLUSION: A pandemic roster plan to minimise staff exposure from other colleagues during a pandemic was possible. This helps to ensure an adequate workforce in the unfortunate event a staff contracts the disease leading to other close contact staff requiring isolation or succumbing to the same illness.

Diagnostic error in an ophthalmic emergency department.

Background Diagnostic error is a major preventable cause of harm to patients. There is currently limited data in the literature on the rates of misdiagnosis of doctors working in an ophthalmic emergency department (ED). Misdiagnosis was defined as a presumed diagnosis being proven incorrect upon further investigation or review. Methods In this retrospective audit, data was collected and analysed from 1 week of presentations at the Royal Victorian Eye and Ear Hospital (RVEEH) ED. Results There were 534 ophthalmic presentations during the study period. The misdiagnosis rates of referrers were: general practitioners (30%), optometrists (25.5%), external hospital EDs (18.8%), external hospital ophthalmology departments (25%) and private ophthalmologists (0%). Misdiagnosis rates of RVEEH doctors were: emergency registrars (7.1%), RVEEH residents (16.7%), first-year registrars (5.1%), second-year registrars (7.1%), third-year registrars (7.7%), fourth-year registrars (0%), senior registrars (6.9%), fellows (0%) and consultants (8.3%). Conclusions The misdiagnosis rates in our study were comparable to general medical diagnostic error rates of 10-15%. This study acts as a novel pilot; in the future, a larger-scale multi-centre audit of ophthalmic presentations to general emergency departments should be undertaken to further investigate diagnostic error.

Topical anaesthetic in the treatment of corneal epithelial defects: What are the risks?

BACKGROUND: Recent publications have suggested that  topical anaesthetic eye drops can be used safely and are effective in providing pain relief for the treatment of corneal abrasions. Complications resulting from the injudicious prescribing of topical anaesthetic eye drops are seen with some frequency in the Royal Victorian Eye and Ear Hospital's (RVEEH's) emergency department. OBJECTIVE: The aim of this article is to review the literature and provide a clinical perspective to challenge the safety of topical anaesthetic eye drops for corneal abrasions. DISCUSSION: The literature relevant to this clinical question is reviewed, with an emphasis on a critical evaluation of the publications in question. Cases from the RVEEH are used for illustrative purpose. An alternative option for analgesia is suggested.

Epidemiology of uveitis in urban Australia.

IMPORTANCE: Few prior studies have described the epidemiology of uveitis in the Australian population. BACKGROUND: To report the incidence and period prevalence of active uveitis in Melbourne and detail their subtypes and aetiologies. DESIGN: Cross-sectional study using retrospective medical record review in a tertiary hospital. PARTICIPANTS: Patients with a coded diagnosis of uveitis who attended the emergency department or specialist ocular immunology clinic at the Royal Victorian Eye and Ear Hospital between November 2014 through October 2015 (N = 1752). METHODS: Medical records were reviewed to confirm the date of diagnosis and subtype of uveitis. Incidence and prevalence rates were calculated utilizing estimates of the adult population residing in areas of greater Melbourne with more than 30 ocular-related presentations to the emergency department annually. MAIN OUTCOMES AND MEASURES: Presence and date of onset, anatomical distribution and aetiology of uveitis. RESULTS: During the study period, 734 new cases of uveitis and 502 cases of pre-existing uveitis requiring active treatment were confirmed. These figures yielded an incidence of 21.54 (CI 20.03, 23.15) per 100 000 person-years and a period prevalence of 36.27 (CI 34.30, 38.35) per 100 000 persons. The distribution of prevalent uveitis cases was anterior (75%), intermediate (6%), posterior (15%) and panuveitis (4%). An infectious aetiology accounted for 13.4% of cases, a systemic associated disease for 26.4% of cases, and no cause was identified in 60.2% of cases. CONCLUSION AND RELEVANCE: The incidence and prevalence rates of uveitis in urban Australia were lower than recent studies from the United States and Europe.

Impact of scribes on emergency medicine doctors' productivity and patient throughput: multicentre randomised trial.

OBJECTIVES: To evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput. DESIGN: Randomised, multicentre clinical trial. SETTING: Five emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit. PARTICIPANTS: 88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site. INTERVENTIONS: Physicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018. MAIN OUTCOME MEASURES: Physicians' productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians' productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done. RESULTS: Data were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians' productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub-acute/fast track regions. No significant harm involving scribes was reported. The cost-benefit analysis based on productivity and throughput gains showed a favourable financial position with use of scribes. CONCLUSIONS: Scribes improved emergency physicians' productivity, particularly during primary consultations, and decreased patients' length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia's. TRIAL REGISTRATION: ACTRN12615000607572 (pilot site); ACTRN12616000618459.

Lessons learnt from incidents involving the airway and breathing reported from Australasian emergency departments.

OBJECTIVE: To review incident reports relating to problems encountered during the ED management of patients with 'airway or breathing' problems, with the aim of finding and highlighting common themes within these rare events, and making recommendations to further improve patient safety in the areas in which deficiencies have been identified. METHODS: Thematic analysis of 36 incidents reported from Australasian EDs, which were related to problems with airway and breathing. RESULTS: In all, 51 problems were identified among the 36 incidents related to airway and/or breathing. Fourteen involved clinical decision-making, 11 equipment, nine communication, seven intubation, five surgical access and five pneumothorax. Eight incidents involved children and there were nine deaths within hours or days. CONCLUSIONS: Recommendations for improving preparedness of ED staff and facilities have been made for each of the problem areas identified with respect to clinical practice, equipment, communication and clinical process. Analysis of incidents from the Australasian Emergency Medicine Events Register allows clusters of like-events to be identified and characterised, providing the possibility of getting a better idea of how problems present and progress, with some information about contributing factors, characteristics and context. This will pave the way for earlier and better detection of life-threatening problems and the development and reinforcement of preventive and corrective strategies.