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Cases & Commentaries
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F. Daniel Duffy, MD; Christine K. Cassel, MD; October 2007
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
Perspectives on Safety > Annual Perspective
with commentary by Sumant Ranji, MD, Educating Practitioners in Safety and Quality, 2014
Elstein AS. Boston, MA: Harvard University Press; 1978.
Clinical reasoning lies at the heart of formulating diagnoses and selecting treatments. The results of these medical decisions determine a substantial portion of the dollars spent on health care. Considering the fundamental importance of clinical reasoning, the topic has received surprisingly little systematic study. Even with the widespread interest in medical error and patient safety in recent years, diagnostic errors and other errors in clinical reasoning have received little attention. This classic collection of empiric studies on clinical reasoning in action thus remains highly relevant more than 25 years after its original publication. One finding of particular relevance for those interested in patient safety and quality improvement is that competence may be problem specific; thus, there is no generic approach to clinical problem solving that, when followed, ensures excellent, or even competent, performance in a variety of domains within a field. The authors also provide an excellent overview of theoretic models relevant to the study of clinical reasoning.
Journal Article > Study
Reed DA, Levine RB, Miller RG, et al. J Gen Intern Med. 2008;23:1084-1089.
Journal Article > Study
Does simulator-based clinical performance correlate with actual hospital behavior? The effect of extended work hours on patient care provided by medical interns.
Gordon JA, Alexander EK, Lockley SW, et al; Harvard Work Hours, Health, and Safety Group (Boston, Massachusetts). Acad Med. 2010;85:1583-1588.
Journal Article > Review
Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis.
Snowdon DA, Hau R, Leggat SG, Taylor NF. Int J Qual Health Care. 2016;28:447-455.
The patient safety movement catalyzed a well-known change in physician duty hours. A less known consequence of duty hour reform was an increase in clinical supervision for trainees. Although some studies have suggested that more clinical supervision leads to fewer adverse events, there were concerns that excessive trainee supervision impedes clinical learning. This systematic review examined how increased clinical supervision affects patient safety. Investigators found that complications from surgery and other invasive procedures were less likely when there was more supervision. Their data also indicated an overall mortality benefit associated with clinical supervision, but this result remains open to question because several of the included studies on mortality were of lower quality. At minimum, this meta-analysis argues for continued clinical supervision of surgeries and invasive procedures for optimal patient safety, as discussed in a previous PSNet perspective.