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1.
J Gen Intern Med ; 2021 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-33575908

RESUMO

Diagnostic errors are a source of unacceptable harm in health care. However, improvement efforts have been hampered by the lack of valid measures reflecting the quality of the diagnostic process. At the same time, it has become apparent that the healthcare work system, particularly in primary care, is chaotic and stressful, leading to clinician burnout and patient harm. We propose a new construct that health systems and researchers can use to measure the quality and safety of the diagnostic process that is sensitive to the context of the health care work system. This model focuses on three measurable practices: considering "don't miss" diagnoses, looking for red flags, and ensuring that clinicians avoid common diagnostic pitfalls. We believe that the performance of clinicians with respect to these factors is sensitive to the health care work system, allowing for context-dependent measurement and improvement of the diagnostic process. Such process measures will enable more rapid improvements rather than exclusively measuring outcomes related to "correct" or "incorrect" diagnoses.

2.
Nurs Outlook ; 2021 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-33455815

RESUMO

Diagnostic errors are among the most common medical errors and the deadliest. The National Academy of Medicine recently concluded that diagnostic errors represent an urgent national concern. Their first recommendation to address this issue called for promoting the key role of the nurse in the diagnostic process. Registered nurses across clinical settings significantly contribute to the medical diagnostic process, though their role in diagnosis has historically gone unacknowledged. In this paper, we review the history and current state of diagnostic education in pre-licensure registered nurse preparation, introduce interprofessional individual- and team-based competencies to improve diagnostic safety, and discuss the next steps for nursing education. Nurses educated and empowered to fully participate in the diagnostic process are essential for achieving better, safer patient outcomes.

3.
Diagnosis (Berl) ; 2021 Jan 18.
Artigo em Inglês | MEDLINE | ID: mdl-33470950

RESUMO

We describe the case of Jessica Barnett, an adolescent girl whose repeated episodes of syncope and near-syncope were ascribed to a seizure or anxiety disorder. The correct diagnoses (congenital long QT syndrome; arrythmogenic right ventricular cardiomyopathy) were established by autopsy and genetic studies only after her death at age 17. The perspective of the family is presented, along with an analysis of what went right and what went wrong in Jessica's diagnostic journey. Key lessons in this case include the value of family as engaged members of the diagnostic team, that a 'hyperventilation test' should not be used to exclude cardiac origins of syncope or pre-syncope, and the inherent challenges in the diagnosis of the long QT syndrome.

6.
Diagnosis (Berl) ; 7(3): 307-312, 2020 08 27.
Artigo em Inglês | MEDLINE | ID: mdl-32697754

RESUMO

Teamwork is fundamental for high-quality clinical reasoning and diagnosis, and many different individuals are involved in the diagnostic process. However, there are substantial gaps in how these individuals work as members of teams and, often, work is done in parallel, rather than in an integrated, collaborative fashion. In order to understand how individuals work together to create knowledge in the clinical context, it is important to consider social cognitive theories, including situated cognition and distributed cognition. In this article, the authors describe existing gaps and then describe these theories as well as common structures of teams in health care and then provide ideas for future study and improvement.

11.
Acad Med ; 95(8): 1162-1165, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-31977340

RESUMO

Diagnosis is the cornerstone of providing safe and effective medical care. Still, diagnostic errors are all too common. A key to improving diagnosis in practice is improving diagnosis education, yet formal education about diagnosis is often lacking, idiosyncratic, and not evidence based. In this Invited Commentary, the authors describe the outcomes of a national consensus project to identify key competencies for diagnosis and the themes that emerged as part of this work. The 12 competencies the authors describe span 3 categories-individual, teamwork, and system related-and address ideal diagnostic practice for all health professionals. In addition, the authors identify strategies for improving diagnosis education, including the use of theory-based pedagogy and interprofessional approaches, the recognition of the role of the health care system to enhance or inhibit the diagnostic process, and the need to focus on the individual attributes necessary for high-quality diagnosis, such as humility and curiosity. The authors conclude by advocating for increasing and improving the assessment of individual and team-based diagnostic performance in health professions education programs.


Assuntos
Competência Clínica , Tomada de Decisão Clínica , Educação Médica , Diagnóstico , Humanos
12.
Diagnosis (Berl) ; 7(1): 45-53, 2020 01 28.
Artigo em Inglês | MEDLINE | ID: mdl-31539352

RESUMO

Background Miscommunication amongst providers is a major factor contributing to diagnostic errors. There is a need to explore the current state of communications between clinicians and diagnostic radiologists. We compare and contrast the perceptions, experiences, and other factors that influence communication behaviors about diagnostic errors between clinicians and radiologists. Methods A survey with questions addressing (1) communication around diagnostic error, (2) types of feedback observed, (3) the manner by which the feedback is reported, and (4) length of time between the discovery of the diagnostic error and disclosing it was created and distributed through two large academic health centers and through listservs of professional societies of radiologists and clinicians. Results A total of 240 individuals responded, of whom 58% were clinicians and 42% diagnostic radiologists. Both groups of providers frequently discover diagnostic errors, although radiologists encounter them more frequently. From the qualitative analysis, feedback around diagnostic error included (1) timeliness of error, (2) specificity in description or terminology, (3) collegial in delivery, and (4) of educational value through means such as quality improvement. Conclusions Clinicians and radiologists discover diagnostic errors surrounding the interpretation of radiology images, although radiologists discover them more frequently. There is significant opportunity for improvement in education and practice regarding how radiologists and clinicians communicate as a team and, importantly, how feedback is given when an error is discovered. Educators and clinical leaders should consider designing, implementing, and evaluating strategies for improvement.


Assuntos
Erros de Diagnóstico/prevenção & controle , Médicos/estatística & dados numéricos , Radiologistas/estatística & dados numéricos , Radiologia/educação , Competência Clínica/normas , Erros de Diagnóstico/estatística & dados numéricos , Humanos , Comunicação Interdisciplinar , Segurança do Paciente/normas , Melhoria de Qualidade , Inquéritos e Questionários/normas , Estados Unidos/epidemiologia
14.
15.
JMIR Med Educ ; 5(2): e14651, 2019 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-31674919

RESUMO

BACKGROUND: Medical education outcomes and clinical data exist in multiple unconnected databases, resulting in 3 problems: (1) it is difficult to connect learner outcomes with patient outcomes, (2) learners cannot be easily tracked over time through the education-training-practice continuum, and (3) no standard methodology ensures quality and privacy of the data. OBJECTIVE: The purpose of this study was to develop a Medical Education Outcomes Center (MEOC) to integrate education data and to build a framework to standardize the intake and processing of requests for using these data. METHODS: An inventory of over 100 data sources owned or utilized by the medical school was conducted, and nearly 2 dozen of these data sources have been vetted and integrated into the MEOC. In addition, the American Medical Association (AMA) Physician Masterfile data of the University of Minnesota Medical School (UMMS) graduates were linked to the data from the National Provider Identifier (NPI) registry to develop a mechanism to connect alumni practice data to education data. RESULTS: Over 160 data requests have been fulfilled, culminating in a range of outcomes analyses, including support of accreditation efforts. The MEOC received data on 13,092 UMMS graduates in the AMA Physician Masterfile and could link 10,443 with NPI numbers and began to explore their practice demographics. The technical and operational work to expand the MEOC continues. Next steps are to link the educational data to the clinical practice data through NPI numbers to assess the effectiveness of our medical education programs by the clinical outcomes of our graduates. CONCLUSIONS: The MEOC provides a replicable framework to allow other schools to more effectively operate their programs and drive innovation.

16.
J Gen Intern Med ; 34(10): 2062-2067, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31388904

RESUMO

BACKGROUND: Venous thromboembolism includes deep vein thrombosis (DVT) and pulmonary embolism. Compression ultrasonography is the most common way to evaluate DVT and is typically performed by sonographers and interpreted by radiologists. Yet there is evidence that ultrasound examinations can be safely and accurately performed by clinicians at the bedside. OBJECTIVE: To measure the operating characteristics of hospital medicine providers performing point-of-care ultrasound (POCUS) for evaluation of DVT. DESIGN: This is a prospective cohort study enrolling a convenience sample of patients. Hospital medicine providers performed POCUS for DVT and the results were compared with the corresponding formal vascular study (FVS) interpreted by radiologists. PARTICIPANTS: Hospitalized non-ICU patients at four tertiary care hospitals for whom a DVT ultrasound was ordered. MAIN MEASURES: The primary outcomes were the sensitivity, specificity, and predictive values of the POCUS compression ultrasound compared with a FVS. The secondary outcome was the elapsed time between order and the POCUS study compared with the time the FVS was ordered to when the formal radiology report was finalized. KEY RESULTS: One hundred twenty-five limbs from 73 patients were scanned. The prevalence of DVT was 6.4% (8/125). The sensitivity of POCUS for DVT was 100% (95% CI 74-100%) and specificity was 95.8% (95% CI 91-98%) with a positive predictive value of 61.5% (95% CI 35-84%) and a negative predictive value of 100% (95% CI 98-100%). The median time from order to POCUS completion was 5.8 h versus 11.5 h median time from order until the radiology report was finalized (p = 0.001). CONCLUSION: Hospital medicine providers can perform compression-only POCUS for DVT on inpatients with accuracy similar to other specialties and settings, with results available sooner than radiology. The observed prevalence of DVT was lower than expected. POCUS may be reliable in excluding DVT but further study is required to determine how to incorporate a positive POCUS DVT result into clinical practice.


Assuntos
Médicos Hospitalares/normas , Testes Imediatos/organização & administração , Ultrassonografia/métodos , Trombose Venosa/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sensibilidade e Especificidade , Fatores de Tempo
17.
J Gen Intern Med ; 34(10): 1960, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31236892
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