Diagnostic Reasoning and Cognitive Biases of Nurse Practitioners.

BACKGROUND: Diagnostic reasoning is often used colloquially to describe the process by which nurse practitioners and physicians come to the correct diagnosis, but a rich definition and description of this process has been lacking in the nursing literature. METHOD: A literature review was conducted with theoretical sampling seeking conceptual insight into diagnostic reasoning. RESULTS: Four common themes emerged: Cognitive Biases and Debiasing Strategies, the Dual Process Theory, Diagnostic Error, and Patient Harm. Relevant cognitive biases are discussed, followed by debiasing strategies and application of the dual process theory to reduce diagnostic error and harm. CONCLUSION: The accuracy of diagnostic reasoning of nurse practitioners may be improved by incorporating these items into nurse practitioner education and practice. [J Nurs Educ. 2018;57(4):203-208.].

Bronchopulmonary sequestration: Improving practice by evaluating for a missed diagnosis.

Bronchopulmonary sequestration (BPS) is a lung mass that does not communicate with the tracheobronchial tree or the pulmonary arterial vasculature, and thus does not play a role in oxygenation. This article discusses the etiology of BPS, as well as its pathophysiology, signs and symptoms, imaging studies used to diagnose, and treatment options in both pediatric and adult patients.

Evitar errores comunes en la realización de un electrocardiograma / Avoid common mistakes in realization of a electrocardiogram

Introducción. El electrocardiograma (ECG) es una técnica no invasiva sencilla de realizar, económica, reproducible y que aporta información valiosa que puede utilizarse para la realización del diagnóstico del paciente y para dirigir las decisiones clínicas. Es una prueba de diagnóstico utilizada con frecuencia, que puede realizarse con rapidez -puesto que se realiza generalmente con un equipo portátil- y que se efectúa normalmente en cualquier ámbito, ya sea de Atención Primaria, atención especializada o extrahospitalaria. El diagnóstico realizado mediante el ECG se considera válido en la práctica asistencial, pero solo resulta efectivo si los electrodos se colocan en las localizaciones anatómicas correctas, si se unen adecuadamente los latiguillos a sus electrodos, si el registro mantiene una buena calidad (se utilizan los filtros apropiados, se evitan interferencias y ruido eléctrico) y se comparan los ECG realizados mediante el mismo sistema de registro (ECG de 5 o 10 latiguillos) para la determinación de cambios evolutivos (como para determinar cambios en el segmento ST durante la isquemia miocárdica o para valorar los cambios producidos por las terapias de reperfusión). Objetivo. Identificar los errores más usuales en electrocardiografía, que se relacionan con las colocaciones inadecuadas de derivaciones, cruce o intercambio de latiguillos de derivaciones de miembros, registros de poca calidad y comparaciones de ECG seriadas realizados con sistemas de adquisición diferentes (10 frente a 5 latiguillos). Conclusiones. Se realizan las recomendaciones para prevenir y evitar estos errores, que pueden conducir a diagnósticos y tratamientos con resultados adversos para el paciente (AU)

Introduction. The electrocardiogram (ECG) is a noninvasive technique to perform simple, economical, reproducible and provides valuable information that can be used to make the diagnosis of the patient and to guide clinical decisions. It is a diagnostic test used frequently as it can be done quickly, since it is done with a laptop and generally is always possible implementation in any field either primary care, specialty outpatient care. The diagnosis made by the ECG is considered valid in clinical practice, but is only effective if the electrodes are placed in the correct anatomical locations, if the hoses are properly attached to the electrodes, the registry maintains a good quality (the filters are used appropriate, interference and electrical noise are avoided) and ECG compares made by the same registration system (ECG 5 or 10 lead) for determining evolutionary changes (to determine changes in the ST segment during myocardial ischemia or assess the changes caused by reperfusion therapies). Objective. To review the most common errors in electrocardiography, which are related to inappropriate placements of shunts, cross or exchange of patch cords limb leads, records of poor quality and comparisons of ECG serials made with different acquisition systems (10 vs 5 lead). Conclusions. We make the recommendations to prevent and avoid these scams that can lead to diagnosis and treatment with adverse outcomes for the patient (AU)

Relevancia de las enfermeras en los errores en la fase preanalítica. Su relación con la seguridad del paciente / Relevance of nurses on the preanalytic phase and patient safety implications

Introducción. La seguridad del paciente constituye en la actualidad uno de los pilares básicos para garantizar la prestación de una atención sanitaria de calidad. Dentro de los tres periodos o fases del proceso laboratorio, es en el primero (el preanalítico) en el que más errores se cometen. Es este el periodo en la que más implicadas están las enfermeras, que deben intervenir en la prevención y detección de estos problemas. Metodología. Se realiza una revisión de la literatura con el objetivo de identificar los errores más frecuentes en esta fase, los factores relacionados, las medidas enfocadas a su detección así como las actuaciones llevadas a cabo para su prevención y control. Se enfatiza en la importancia de las enfermeras en este ámbito, ya que muchos de los errores están relacionados con la toma de muestras. Conclusiones. Como conclusión, cabe destacar la importancia de establecer estándares para una práctica clínica fiable, eficaz y segura, identificar las áreas de mejora y plantear programas formativos que contribuyan a disminuir el riesgo de errores y la variabilidad clínica, con especial mención al papel de las enfermeras en esta etapa (AU)

Introduction. Nowadays, the patient’s safety is considered one of the pillars in a high quality clinical assistance. Inside three steps of laboratory process, it is in the first one, the preanalytical, where most mistakes are made. Nurses are very involved in the development of this period because it is where is included the sampling. Methodology. We reviewed the literature with the aim to identify the most frequent mistakes, the related factors, the measures taken for its detection and prevention. It emphasizes the importance of nurses in this area, as many of the errors are related to sampling. Conclusions. We conclude that it is very important to establish suitable and safe clinical practice standards, identifying improvement areas and planning training programs which contributes to decrease the mistake risk and clinical variability, with special mention to the nurses at this stage (AU)

Older adults and new-onset epilepsy: experiences with diagnosis.

BACKGROUND AND PURPOSE: The incidence of new-onset epilepsy is highest in older adults. Research has revealed that epilepsy diagnosis in older adults is difficult and often delayed. However, in-depth qualitative inquiry is needed to more richly describe older adults' experiences with being diagnosed with epilepsy to reveal the context in which these delays occur and the effects on older adults. METHODS: A qualitative descriptive approach was used to describe the diagnosis experiences of 20 older adults with new-onset epilepsy. Semistructured interviews were used to generate data. All data were transcribed verbatim and analyzed via conventional content analysis. RESULTS: A delayed diagnosis of epilepsy was pervasive in the sample, and participants attributed delays to both their actions and their care providers' actions. Women experienced delays more often than men. Experiences of those whose diagnoses were not delayed are also discussed. Research using larger and more diverse samples is needed to investigate the scope of diagnosis delays in this population as well as to design interventions to improve the diagnosis process for older adults with new-onset epilepsy.

Safety in numbers 2: Competency modelling and diagnostic error assessment in medication dosage calculation problem-solving.

Accurately defining and modelling competence in medication dosage calculation problem-solving (MDC-PS) is a fundamental pre-requisite to measuring competence, diagnosing errors and determining the necessary design and content of professional education programmes. In this paper we advance an MDC-PS competence model that illustrates the relationship between conceptual competence (dosage problem-understanding), calculation competence (dosage-computation) and technical measurement competence (dosage-measurement). To facilitate bridging of the theory-practice gap it is critical that such models are operationalised within a wider education framework that supports the learning, assessment and synthesis of cognitive competence (the knowing that and knowing why of MDC-PS) and functional competence (the know-how and skills associated with the professional practice of MDC-PS in clinical settings). Within the context of supporting the learning and diagnostic assessment of MDC-PS we explore PhD fieldwork that challenges the value of pedagogical approaches that focus solely on abstract information, that isolate the process of knowledge construction from its application in practice settings and contribute to the generation of conceptual errors. We consider misconceptions theory and the concept of mathematical 'dropped stitches' and offer an assessment model and program designed to diagnose flawed arithmetical operation and computation constructs.

Seguridad de los pacientes en una uci. Percepción enfermera / Cost-effectiveness of a tlc-nosf polyurethane foam dressing

La seguridad de los pacientes y la prevención de los errores que pueden alterarla emergen como una nueva dimensión de los cuidados de enfermería a lo largo de la última década. Nuestro trabajo, utilizando una metodología cualitativa, nos ha permitido identificar veinticinco situaciones y actividades enfermeras en las que existen riesgo de errores; en todas ellas, las enfermeras que han participado en el estudio creen que se puede mejorar la seguridad del paciente; así mismo, se considera que las que conllevan mayor riesgo de error son: la documentación escrita a mano, el manejo de fármacos, los cambios de turno, la falta de entrenamiento en determinadas situaciones, y la ausencia de reuniones de trabajo multidisciplinar. Nuestro estudio ha permitido obtener una percepción global de la seguridad de los pacientes desde la perspectiva enfermera en una Unidad de Cuidados Intensivos (UCI)(AU)

Chronic wounds represent a drain on the Spanish health system, nowdays is necessary an optimization of the resources used and that is for this that is necessary justify the use of the products over others through cost-effective studies for to show the economic benefit to professionals and the life quality of patient. This article compares the use of a new technology for format polyurethane foam, TLC-NOSF, with the most commonly used products for treating wounds. This comparison is made using a cost-effectiveness model (Markov Model). The results demonstrate that treatment with polyurethane foam dressing with TLC-NOSF are cost-effective versus treatments with polyurethane foams most commonly used in Spain(AU)

An initiative by midlevel providers to conduct tertiary surveys at a level I trauma center.

INTRODUCTION: Increased patient volume and residents' work hour restrictions have escalated the workload at trauma centers. Because tertiary surveys (TSs) are integral to care, midlevel providers (MLPs) can help streamline this time-consuming process. In this study, we implemented a care plan in which MLPs conduct all TSs, initiate appropriate consultations, and offload residents' work hours. METHODS: From January 2007 to December 2008, we conducted a prospective evaluation of an initiative in which MLPs performed all TSs within 48 hours of admission. A TS consisted of a complete history and physical examination, follow-up of radiologic interpretations, and appropriate consultations. Data included patient demographics, incidence of additional diagnoses noted during TSs and reduction in residents' work hours. Data are presented as mean +/- standard error. RESULTS: During the 2-year period, there were 5,143 patients admitted to the trauma service. The mean age was 36 years +/- 4.8 years, and mean Injury Severity Score (ISS) was 14.2 +/- 4.2. Overall mortality was 5%. Blunt mechanisms accounted for 85%, and penetrating mechanisms resulted in 14% of injuries. MLPs conducted TSs in 56% of patients during the first year and 76% in the second year. In 80 patients (mean age of 44 years +/- 7.1 years, mean Injury Severity Score 21.7 +/- 2.8; p < 0.05 vs. entire cohort), TSs revealed additional injuries, for an incidence of 1.5%. The majority of these diagnoses were of "minor" fractures, half requiring consultations, and 9% necessitating operative intervention. Residents' workload was reduced by 1,802 hours. CONCLUSIONS: Implementation of a MLP initiative to conduct TSs in trauma patients can achieve a consistent and comprehensive workup while offsetting residents' workload and helping to ensure compliance with the 80-hour resident work policy.

An uncommon skin condition illustrates the need for caution when prescribing for friends.

PURPOSE: A dual-focused case study written to discuss the legal and medical hazards of informally writing prescriptions for friends or family members and to provide knowledge of early-stage mycosis fungoides (MF), its course, and treatment. DATA SOURCES: A review of the prescribing practices of clinicians, the cognitive processes needed in diagnosis and treatment, the current ethical guidelines, and a review of MF, its course, and treatments. CONCLUSIONS: Treating acquaintances and family informally places clinicians at risk for liability and patients at risk for inaccurate diagnosis and treatment. This case illustrates the potential hazard of casually treating a friend for what looks like a benign condition. Resembling atopic dermatitis in its early stages, MF is the most common of a rare group of skin lymphomas. Early diagnosis and treatment are crucial for a better prognosis. Had this clinician complied with the request of her friend, his diagnosis would have been missed and timely treatment delayed. IMPLICATIONS FOR PRACTICE: No matter what the prior relationship may have been, once a clinician treats a patient, a legally binding relationship begins, requiring the due standard of care. Nurse practitioners (NPs) need to be aware of the potential for error when treating acquaintances. Available NP standards of practice and ethical guidelines should address informal treatment situations.

Under diagnosis of alcohol misuse in the older adult population.

Alcohol abuse in older adults is common, yet it is often under detected and misdiagnosed, and as a result associated with considerable morbidity. There is growing concern that as the population ages, there will be a substantial increase in the number of older adults needing treatment for alcohol misuse and currently, little is done to identify and address this situation. Factors contributing to under diagnosis include, but are not limited to, depression, dementia, physical changes associated with age, life events, late onset of alcoholism and lack of screening. A case report is presented and existing research findings are discussed. The importance of assessment, the use of screening tools, treatment issues and identification of other comorbidities are presented. The focus on increased awareness among clinicians as well as their role in identifying and addressing alcohol abuse issues in the older adult population is explored.