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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
Learning from mistakes: factors that influence how students and residents learn from medical errors.
Fischer MA, Mazor KM, Baril J, Alper E, DeMarco D, Pugnaire M. J Gen Intern Med. 2006;21:419-423.
Investigators conducted and analyzed nearly 60 structured interviews with medical trainees and categorized the factors that influenced their learning from errors. These factors were grouped as topic areas, which included awareness of error, factors influencing learner response (eg, personality, hidden curriculum), types of responses reported (eg, emotional, cognitive), and formal teaching. The authors discuss recommendations and specific educational methods that may promote improved learning from errors for trainees. A past study discussed one of these methods, Morbidity and Mortality Conferences, as a place to discuss medical errors with an educational focus.
Journal Article > Commentary
Shojania KG, Fletcher KE, Saint S. Ann Intern Med. 2006;145:592-598.
This case study presents the events surrounding the death of a woman admitted to an academic medical center with pancreatitis. The discussion analyzes the sequence of errors that transpired from initial delays in diagnosis and treatment to poor communication and handoffs (the latter is a 2007 National Patient Safety Goal). The authors also explore the common yet unresolved tension in teaching hospitals for attending physicians who must provide appropriate supervision of trainees while also allowing autonomy for growth. This article is the last of a special collection entitled "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors. An accompanying editorial (available via the link below) by the series editors reflects on the experiences of producing the 13 articles in this collection, the patient safety movement in general, and the importance of sharing these stories as educational tools to drive improvement.
Journal Article > Study
A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors.
Hickson GB, Pichert JW, Webb LE, Gabbe SG. Acad Med. 2007;82:1040-1048.
Efforts to address professionalism and individual accountability remain important in patient safety, even with the role systems play in poor patient outcomes. Past studies have tried to predict poor professional behavior based on medical school performance, and concerns have also been raised as a result of changes in residency training requirements. This article describes the efforts of one academic institution in teaching professionalism. The authors share their approach and model for addressing disruptive behavior, and their related interventions to prevent it. An AHRQ WebM&M conversation and commentary also discuss professionalism and patient safety.
Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; March 2010.
Medical schools face an urgent need to transform their curricula to emphasize patient safety, according to this report from the Lucian Leape Institute at the National Patient Safety Foundation. Based on a roundtable discussion among leading medical education and patient safety experts, this report concludes that the traditional curricular focus on medical knowledge and technical expertise must shift to incorporate key concepts in systems analysis and patient-centered care. The piece includes specific recommendations for medical school and academic medical center leadership to develop rigorous safety curricula and evaluation methods. The report also emphasizes the importance of a culture of safety in teaching hospitals, stressing that unprofessional behavior and authority gradients prevent students from reporting and learning from errors.
Journal Article > Review
Wong BM, Etchells EE, Kuper A, Levinson W, Shojania KG. Acad Med. 2010;85:1425-1439.
A recent report by the National Patient Safety Foundation called for medical schools and residency programs to reengineer their curricula to emphasize patient safety and quality improvement (QI) concepts. This systematic review evaluated the published literature on existing safety and QI curricula, and found that curricula were generally popular among trainees and resulted in increased knowledge of safety or QI concepts. Curricula focused on teaching systems analysis and continuous quality improvement principles, and some studies did find improvement in care processes associated with the educational intervention.
Journal Article > Study
Patients as teachers: a randomised controlled trial on the use of personal stories of harm to raise awareness of patient safety for doctors in training.
Jha V, Buckley H, Gabe R, et al. BMJ Qual Saf. 2015;24:21-30.
In a 2010 report, patient safety was described as a critical unmet need in medical and nursing education. Formal curricula have emerged, but incorporating these ideals into trainees' practices remains challenging. This randomized controlled trial compared two educational strategies, patient narratives of health-related harm versus traditional faculty-delivered teaching, on the attitudes of physicians-in-training towards patient safety. Using the Attitude to Patient Safety Questionnaire, researchers found no differences in the two groups. Those learners who received patient narrative teaching demonstrated both stronger negative and positive reactions to the curriculum than those receiving traditional instruction. These results suggest that patient narratives alone are unlikely to change trainee physicians' attitudes toward patient safety. A past AHRQ WebM&M perspective discusses the role of graduate medical education in patient safety.
Journal Article > Study
Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.
Martinez W, Lehmann LS, Thomas EJ, et al. BMJ Qual Saf. 2017;26:869-880.
Health care provider comfort with raising patient safety concerns is a critical aspect of safety culture. This survey of resident physicians at six academic medical centers demonstrated that trainees remain reluctant to speak up. Nearly half reported observing a patient safety threat. The majority spoke up about patient safety concerns, but a significant proportion did not. Although unprofessional behavior was more frequently observed, fewer trainees raised concerns about lack of professionalism than about patient safety. Even when respondents perceived the unprofessional behavior as having high potential for adverse patient consequences, they were not as likely to speak up about this compared to a traditional patient safety threat such as inadequate hand hygiene. The authors recommend specifically measuring tolerance for unprofessional behaviors as a part of safety culture assessment.