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Journal Article > Study
Singh H, Davis Giardina T, Petersen LA, et al. BMJ Qual Saf. 2012;21:30-38.
Diagnostic errors are a known threat to patient safety, and measuring their prevalence is challenging, particularly outside pathology and radiology settings. Past studies have highlighted classification systems and related prevention strategies, including the adoption of checklists. This study explored the use of a situational awareness (SA) framework to understand diagnostic errors in a primary care setting. Investigators interviewed providers involved in a diagnostic error and revealed that one level of SA was lacking (e.g., information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels). The authors found that applying the SA framework to analyze such errors provided deeper insight into the provider–work system interaction, which included important interface with the electronic health record. A past AHRQ WebM&M perspective and interview discussed diagnostic errors in medicine.
Dixon BE, Hook JM, McGowan JJ, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; December 2008. AHRQ Publication No. 09-0012-EF.
Telehealth is a rapidly expanding approach of adopting technology to deliver health care services and information that improves the quality, safety, access, efficiency, and costs of care. Although the evidence that telehealth achieves these aims is still lacking, this report outlines AHRQ's health information technology portfolio, which funded a number of programs to evaluate this promising technology and approach. The report findings are based on interviews with lead investigators. It discusses the scope of the projects funded, the technical challenges faced, the organizational and cultural issues encountered, and the opportunities ahead.