Accurate and complete clinical documentation is essential to high quality, safe healthcare. In this simulation study, senior medical residents responded to pages regarding sepsis or atrial fibrillation (phone encounter) and documented a brief note regarding the encounter afterwards (documentation encounter). The study found that written documentation following a clinical encounter included more important clinical information (e.g., ordering blood cultures for sepsis, placing a patient on telemetry) compared to what was discussed during the phone encounter.

Context (e.g., patient characteristics, setting) can influence clinical reasoning and increase the risk for diagnostic errors. This article explores the ways in which individual-, team-, and system-level contextual factors impact reasoning, clinician performance and risk of error. The authors propose a multilevel framework to better understand how contextual factors impact clinical reasoning.

Cognitive biases, such as heuristics, help clinicians make rapid decisions, but these biases can result in errors. This review sought to explore biases in internal medicine, the impact of biases on patient outcomes, and the effect of debiasing strategies. Forty-one biases were studied, and debiasing strategies showed little to no effect on reducing bias.

Clinical decision-making is a complex process often involving interactions with multiple team members, processes, and systems. Using distributed cognition theory and qualitative synthesis, this scoping review including 37 articles identified seven themes addressing how distribution of tasks influences clinical decision-making in acute care settings The themes included information flow, task coordination, team communication, situational awareness, electronic health record (EHR) design, systems-level error, and distributed decision-making.

Interventions such as deprescribing, pharmacist involvement, and medication reconciliation are used to reduce polypharmacy and use of high-risk medications such as opioids. In this study, a pharmacist was embedded in general practice to support medication management of high-risk patients. This study presents perspectives of the pharmacists, general practitioners, practice personnel, patients, and carers who participated in the program.

… to improve education in regard to diagnosis. … Graber ML,  Holmboe E, Stanley J, et al. A call to action: next steps to advance diagnosis …

Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. 

… J Surg Educ … An essential part of resident training is error … their error recovery skills. … Gabrysz-Forget F, Zahabi S, Young M, et al. "It's a big part of being good surgeons": …

This study explored the influence of contextual factors (i.e., factors beyond the case content potentially influencing reasoning) on context specificity and clinical reasoning. Internal medicine residents and attending physicians viewed outpatient clinic videos involving unstable angina and diabetes mellitus – one video with distracting contextual factors and one without. The results provide insight into factors influencing diagnostic reasoning during outpatient visits for common medical conditions.

This survey of surgical residents explored their experiences and perceptions of error recovery training (i.e., how to recognize and manage a technical error in order to ensure patient safety). Nearly all respondents thought error recovery was a key competency, yet only one-third felt they were adequately trained to recover from major events. Error recovery should be incorporated into formal surgical curriculum to support trainees and increase surgical safety.

… respiratory symptoms.  … Boyle JG, Walters MR, Jamieson S, Durning SJ. Clinical reasoning in the wild: premature closure …

… J Patient Saf … In this survey of clerkship directors in …

Enhancing clinical reasoning skill, particularly among trainees, is emerging as a strategy to reduce diagnostic error. The authors of this commentary suggests that the Accreditation Council for Graduate Medical Education’s (ACGME) consider revising their core competencies to include clinical reasoning to provide trainees with the tools necessary to monitor and prevent diagnostic errors. 

An international group of educational and health system leaders, educators, front-line clinicians, learners, and patients convened to create a list of actionable strategies that organizations can use to better integrate Quality Improvement Patient Safety (QIPS) education with clinical care. A framework and list of concrete examples describe how groups can get started.

Mitigating diagnostic error has become a critical patient safety concern. As a result, medical education and training programs are increasingly focused on teaching students and residents about diagnostic safety. This article describes the development of a novel interprofessional framework to improve diagnostic competency across health professions education programs. A consensus committee identified 12 key competencies that focus on individual performance (e.g., prioritizing differential diagnosis; utilizing second opinions, decision support, and checklists), teamwork (e.g., engaging patients and families; collaborating with other health professionals), and system-related aspects of clinical care (e.g., developing a culture of diagnostic safety; disclosing and learning from errors). The authors emphasize the innovative aspects of their recommendations and suggest that education programs develop curriculum incorporating these competencies to improve diagnosis. A previous WebM&M commentary discussed an incident involving a diagnostic error.

… evaluate clinical reasoning assessment tools. … Daniel M, Rencic J, Durning SJ, et al. Acad Med. 2019;94:902-912. …

Metacognition is an approach to enhance diagnostic thinking. This study used focus groups to assess physicians' and medical students' impressions of a metacognitive diagnostic checklist. Participants found the checklist to be applicable and usable, and the authors conclude that it should be tested in a clinical setting.

This simulation study presented virtual patient cases to practicing physicians with the aim of improving diagnostic accuracy. Physician participants reported challenges using the computerized platform, and overall diagnostic performance was poor, with less than a third of respondents identifying the correct diagnosis. This study highlights the challenge of developing interventions to enhance diagnostic performance.

Efforts to reduce diagnostic error have mainly focused on safety and quality improvement initiatives. This commentary describes an educational strategy for improving diagnosis. The authors suggest that learners should demonstrate effective use of knowledge, clinical reasoning, system orientation, patient and team engagement, and appropriate attitudes regarding diagnosis to achieve lasting success.

Enhancing clinical reasoning skill is emerging as a strategy to reduce diagnostic error. This review spotlights the need for a uniform definition of clinical reasoning and a robust literature base to augment efforts to improve reasoning and decision making. The authors suggest these refinements will identify cognitive biases and other contextual influences on clinical reasoning and improve education and professional development.