Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making.

Saul J Weiner; Alan Schwartz; Rachel Yudkowsky; Gordon Schiff; Frances M Weaver; Julie Goldberg; Kevin Weiss

Study

Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making.

October 17, 2007

Weiner SJ, Schwartz A, Yudkowsky R, et al. Med Decis Making. 2007;27(6):726-34.

View more articles from the same authors.

This study describes a methodology for measuring physician performance and focuses on the ability to expose forms of contextual error.

PubMed citation

Available at

Related Resources From the Same Author(s)

Uncharted territory: measuring costs of diagnostic errors outside the medical record.

July 25, 2012

Contextual errors and failures in individualizing patient care: a multicenter study.

August 4, 2010

Providers contextualise care more often when they discover patient context by asking: meta-analysis of three primary data sets.

March 2, 2016

Contextual errors in medical decision making: overlooked and understudied.

December 16, 2015

Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients.

May 1, 2020

An educational intervention for contextualizing patient care and medical students' abilities to probe for contextual issues in simulated patients.

October 6, 2010

Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites.

April 19, 2017

Processes for effective communication in primary care.

May 4, 2005

Perceptions of effective and ineffective nurse–physician communication in hospitals.

August 25, 2010

Diagnosis and diagnostic errors: time for a new paradigm.

January 8, 2014

A 60-year-old man with delayed care for a renal mass.

May 18, 2011

A patient safety approach to setting pass/fail standards for basic procedural skills checklists.

November 5, 2014

How can we make diagnosis safer?

February 8, 2012

COVID-19: making the right diagnosis.

August 5, 2020

The elusive and illusive quest for diagnostic safety metrics.

May 16, 2018

Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges.

November 3, 2021

Can electronic clinical documentation help prevent diagnostic errors?

March 31, 2010

Advancing the research agenda for diagnostic error reduction.

August 28, 2013

Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders.

July 26, 2017

Incorporating indications into medication ordering—time to enter the age of reason.

August 10, 2016

Use of health information technology to reduce diagnostic errors.

August 21, 2013

Resident hesitation in the operating room: does uncertainty equal incompetence?

November 21, 2018

Indication alerts intercept drug name confusion errors during computerized entry of medication orders.

September 3, 2014

Ambulatory care adverse events and preventable adverse events leading to a hospital admission.

April 18, 2007

What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors.

March 4, 2020

Strategies for flipping the script on opioid overprescribing.

November 23, 2016

Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors.

September 6, 2017

The global burden of diagnostic errors in primary care.

August 24, 2016

Beyond the prescription: medication monitoring and adverse drug events in older adults.

August 31, 2011

Reduced effectiveness of interruptive drug–drug interaction alerts after conversion to a commercial electronic health record.

May 30, 2018

Computerised prescribing for safer medication ordering: still a work in progress.

November 18, 2015

Association of note quality and quality of care: a cross-sectional study.

April 23, 2014

A prescription for enhancing electronic prescribing safety.

December 12, 2018

Principles of conservative prescribing.

June 29, 2011

Addressing ambulatory safety and malpractice: the Massachusetts PROMISES project.

December 14, 2016

Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs.

June 27, 2018

Missed diagnosis of cancer in primary care: insights from malpractice claims data.

August 7, 2019

Learning from errors: analysis of medication order voiding in CPOE systems.

March 15, 2017

Screening for medication errors using an outlier detection system.

February 8, 2017

Finding and fixing diagnosis errors: can triggers help?

February 1, 2012

Automated detection of look-alike/sound-alike medication errors.

April 12, 2017

The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event investigations.

August 30, 2023

Gaps in pediatric clinician communication and opportunities for improvement.

October 22, 2008

Incorporating medication indications into the prescribing process.

May 9, 2018

Primary care closed claims experience of Massachusetts malpractice insurers.

October 16, 2013

Quality improvement implementation and hospital performance on patient safety indicators.

January 31, 2006

Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors.

August 16, 2017

Burnout in pediatric residents: three years of national survey

January 22, 2020

An initiative to improve the management of clinically significant test results in a large health care network.

October 30, 2013

RaDonda Vaught, medication safety, and the profession of pharmacy: steps to improve safety and ensure justice.

August 17, 2022

Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems.

May 1, 2019

Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.

June 8, 2016

Automated detection of wrong-drug prescribing errors.

August 28, 2019

Using a machine learning system to identify and prevent medication prescribing errors: a clinical and cost analysis evaluation.

December 18, 2019

Primary care collaboration to improve diagnosis and screening for colorectal cancer.

May 3, 2017

Doing right by our patients when things go wrong in the ambulatory setting.

February 12, 2014

Systems engineering analysis of diagnostic referral closed-loop processes.

March 9, 2022

Improving medication error reporting in hospice care.

May 27, 2009

Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool.

May 15, 2013

Exploration of an automated approach for receiving patient feedback after outpatient acute care visits.

July 30, 2014

Measuring and improving diagnostic safety in primary care: addressing the “twin” pandemics of diagnostic error and clinician burnout.

March 3, 2021

Ensuring primary care diagnostic quality in the era of telemedicine.

October 27, 2021

Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive task analysis.

March 10, 2021

Screening for adverse drug events: a randomized trial of automated calls coupled with phone-based pharmacist counseling.

March 6, 2019

Evaluating ambulatory practice safety: the PROMISES Project administrators and practice staff surveys.

December 17, 2014

Diagnostic error in medicine: analysis of 583 physician-reported errors.

November 18, 2009

Patient safety professionals as the third victims of adverse events.

June 26, 2019

Impact of vendor computerized physician order entry in community hospitals.

February 22, 2012

Personal formularies of primary care physicians across 4 health care systems.

August 4, 2021

The problem with Plan-Do-Study-Act cycles.

February 3, 2016

A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites.

May 10, 2017

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.

April 22, 2009

Communicating medication changes to community pharmacy post-discharge: the good, the bad, and the improvements.

September 4, 2013

Identifying hospital organizational strategies to reduce readmissions.

January 9, 2013

Ten principles for more conservative, care-full diagnosis.

October 10, 2018

Randomized trial of reducing ambulatory malpractice and safety risk: results of the Massachusetts PROMISES Project.

July 19, 2017

Quantitative analysis of the content of EMS handoff of critically ill and injured patients to the emergency department.

August 10, 2016

Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication errors.

October 19, 2016

Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study.

February 9, 2022

Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents.

September 18, 2019

Postdischarge adverse events for 1-day hospital admissions in older adults admitted from the emergency department.

April 7, 2010

Improving diagnosis: adding context to cognition.

September 7, 2022

Implementation of a modified bedside handoff for a postpartum unit.

June 21, 2017

Use of unit-based interventions to improve the quality of care for hospitalized medical patients: a national survey.

August 2, 2017

Lessons learned in implementing a chronic opioid therapy management system.

December 21, 2022

How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care.

July 12, 2023

The vulnerabilities of computerized physician order entry systems: a qualitative study.

December 9, 2015

Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals across the UK.

May 30, 2018

Implementing AORN recommended practices for prevention of retained surgical items.

February 15, 2012

Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial.

May 29, 2019

Examining nurses' decision process for medication management in home care.

November 30, 2005

A survey of hospital quality improvement activities.

July 30, 2008

Sidelining safety — the FDA's inadequate response to the IOM.

September 12, 2007

Follow-up tips for a safe, efficient practice.

May 31, 2006

Medical errors: should you apologize?

May 3, 2006

Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation.

July 13, 2022

Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events.

May 25, 2022

Operational rounds: a practical administrative process to improve safety and clinical services in radiology.

November 26, 2008

Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections.

December 12, 2007

Reducing surgical complications.

November 21, 2007

Related Resources

Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis.

September 13, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Video-based communication assessment of physician error disclosure skills by crowdsourced laypeople and patient advocates who experienced medical harm: reliability assessment with generalizability theory.

May 18, 2022

Barriers to accessing nighttime supervisors: a national survey of internal medicine residents.

March 17, 2021

A bottom-up approach addressing patient care and differential diagnosis amidst the Covid-19 response.

October 14, 2020

WebM&M Cases

Think Like a Surgeon

September 25, 2019

Use of "Doctor" badges for physician role identification during clinical training.

September 11, 2019

Influence of doctor–patient conversations on behaviours of patients presenting to primary care with new or persistent symptoms: a video observation study.

August 14, 2019

Impact of critical event checklists on anaesthetist performance in simulated operating theatre emergencies.

July 31, 2019

Mental mayhem: the peril of multitasking in medicine.

July 17, 2019

Inpatient notes: just what the doctor ordered—checklists to improve diagnosis.

May 1, 2019

The "hemolyzed" physical examination—situational challenges to accurate bedside diagnosis.

March 27, 2019

Addressing medicine's bias against patients who are overweight.

March 27, 2019

Guided reflection interventions show no effect on diagnostic accuracy in medical students.

March 20, 2019

Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette study of doctors in three NHS emergency departments in England.

February 27, 2019

Teaching about diagnostic errors through virtual patient cases: a pilot exploration.

February 27, 2019

Patient participation in patient safety—an exploration of promoting factors.

February 13, 2019

Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper.

December 5, 2018

A factorial survey on safety behavior providing opportunities to improve safety.

December 5, 2018

Blinding or information control in diagnosis: could it reduce errors in clinical decision-making?

December 5, 2018

Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors.

October 24, 2018

Ten principles for more conservative, care-full diagnosis.

October 10, 2018

Cognitive error in an academic emergency department.

October 10, 2018

Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy.

November 29, 2017

Patient safety climate strength: a concept that requires more attention.

August 31, 2016

Boosting medical diagnostics by pooling independent judgments.

August 17, 2016

Determinants of patient–oncologist prognostic discordance in advanced cancer.

August 3, 2016

Communication and shared understanding between parents and resident-physicians at night.

July 13, 2016

See More About The Topic

Physicians

Organizational Behaviorists

Internal Medicine

Cognitive Errors ("Mistakes")

Benchmarking

Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site