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Search results for "Education and Training"
- Diagnostic Errors
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Journal Article > Study
Psychiatry morbidity and mortality rounds: implementation and impact.
Goldman S, Demaso DR, Kemler B. Acad Psychiatry. 2009;33:383-388.
Discussion of adverse events in morbidity and mortality (M&M) conferences serves as an important tool for both educational and quality improvement initiatives. This study found that 80% of cases reviewed in monthly psychiatry M&M conferences at a children's hospital provided opportunities for patient care improvement.
Journal Article > Review
Patient safety in geriatrics: a call for action.
Tsilimingras D, Rosen AK, Berlowitz DR. J Gerontol A Biol Sci Med Sci. 2003;58:M813-M819.
This review discusses medication errors and patient safety in the context of geriatrics and offers recommendations to improve safety for elderly patients.
Journal Article > Commentary
Teaching novice clinicians how to reduce diagnostic waste and errors by applying the Toyota Production System.
Radhakrishnan NS, Singh H, Southwick FS. Diagnosis (Berl). 2019 Mar 16; [Epub ahead of print].
The Toyota Production System was designed to support reliable processes that improve value and reduce delays, overuse, and cost. This article describes an initiative to integrate principles of the Toyota Production System into an educational program for improving diagnosis and patient management.
Tools/Toolkit > Government Resource
Reducing Diagnostic Errors in Primary Care Pediatrics (Project RedDE!) Toolkit.
Itasca, IL: American Academy of Pediatrics; 2018.
Diagnostic error prevention in primary care is a persistent challenge. This AHRQ-funded toolkit provides guidance for ambulatory care organizations that seek to improve the reliability of diagnosis in children. The material focuses on tactics to enhance how practices recognize, track, and follow up on adolescent depression, pediatric elevated blood pressure, and actionable laboratory results.
Journal Article > Review
Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review.
Lambe KA, O'Reilly G, Kelly BD, Curristan S. BMJ Qual Saf. 2016;25:808-820.
This systematic review explored interventions to augment diagnostic reasoning among physicians. Cognitive forcing and guided reflection were two strategies that consistently improved cognition. This finding suggests that these methods should be more widely implemented to enhance timely and accurate diagnosis.
Perspectives on Safety > Perspective
Promising Areas for Patient Safety Research
with commentary by P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH, Patient Safety Research, December 2013
This piece, written by three leaders in AHRQ's research portfolio, covers future avenues for patient safety research and reviews current AHRQ projects.
Journal Article > Commentary
From mindless to mindful practice—cognitive bias and clinical decision making.
Croskerry P. N Engl J Med. 2013;368:2445-2448.
Discussing how weaknesses in cognition contribute to flawed decision making, this commentary includes recommendations to help clinicians prevent cognitive failures.
Newspaper/Magazine Article
We know what they did wrong, but not why: the case for 'frame-based' feedback.
Rudolph J, Raemer D, Shapiro J. Clin Teach. 2013;10:186-189.
This commentary describes techniques for providing feedback to clinicians after an error.
Journal Article > Study
Patient record review of the incidence, consequences, and causes of diagnostic adverse events.
Zwaan L, de Bruijne M, Wagner C, et al. Arch Intern Med. 2010;170:1015-1021.
Evidence from autopsy studies indicates that thousands of patients die every year due to missed or delayed diagnoses, leading to diagnostic errors being termed the "next frontier" in patient safety. This Dutch study used trigger methodology (based on the classic Harvard Medical Practice Study) to analyze the epidemiology and underlying causes of diagnostic errors in a broad sample of hospitalized patients. Approximately 1 in 250 patients experienced a diagnostic error, most of which were considered preventable. The contributing factors primarily centered around knowledge-based errors and faulty information transfer between physicians—a problem noted in prior studies of diagnostic errors. A Patient Safety Primer discusses the heuristics that cause physicians to err in the diagnostic process and the system failures that lead to delayed or missed diagnoses.
Journal Article > Study
Reducing inappropriate diagnostic practice through education and decision support.
Bairstow PJ, Persaud J, Mendelson R, Nguyen L. Int J Qual Health Care. 2010;22:194-200.
A decision support program improved adherence to recommended diagnostic algorithms for common emergency department conditions.
Journal Article > Study
Process of care failures in breast cancer diagnosis.
Weingart SN, Saadeh MG, Simchowitz B, et al. J Gen Intern Med. 2009;24:702-709.
Diagnostic errors have been described as the next frontier in patient safety, with past studies discussing their epidemiology and the contributing role of physician overconfidence. This retrospective chart review analyzed cases of recently diagnosed breast cancer to identify patient- and provider-related process of care failures. Investigators targeted those cases where a delay of at least 90 days occurred between symptom onset and diagnosis and found a high rate of process failures. These were attributed to both providers for failing to perform adequate physical exams and patients for failing to undergo recommended tests, as two examples. Missed or delayed cancer diagnoses are a frequent cause of malpractice lawsuits, and errors in cancer diagnosis are also a noted challenge. The authors advocate for the importance of educating and empowering patients as an additional strategy to improve the quality of care.
Cases & Commentaries
Failure to Latch
- Web M&M
Mitch Rodriguez, MD, MBA; Rebecca Mannel, BS, IBCLC; Donna Frye, RN, MN; September 2008
After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.
Audiovisual > Audiovisual Presentation
Preventing Medical Errors.
Food and Drug Administration (FDA) Patient Safety News. Show #79. September 2008.
This collection of video segments offers information on common types of medical errors, particularly medication errors, based on reports to the Institute for Safe Medication Practices.
Journal Article > Review
Overconfidence as a cause of diagnostic error in medicine.
Berner ES, Graber ML. Am J Med. 2008;121(suppl 1):S2-S23.
This comprehensive review analyzes the frequency of diagnostic errors, addresses research on contributing factors, and describes strategies to reduce harm and improve diagnostic accuracy.
Cases & Commentaries
Do Not Disturb!
- Spotlight Case
- Web M&M
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.
Journal Article > Study
Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency?
Giesen P, Ferwerda R, Tijssen R, et al. Qual Saf Health Care. 2007;16:181-184.
Many health systems rely on telephone triage to determine the urgency with which a patient should be seen by a clinician. Prior research has demonstrated that errors in triage may lead to patient harm. In this study, standardized patients with a variety of symptoms contacted telephone triage nurses at four Dutch general practices. The investigators analyzed the accuracy of triage decisions by comparing the nurses' advice to the national guideline for telephone triage. Both underestimation and overestimation of the severity of patients' illnesses occurred, although errors were less frequent when nurses had received specific training in use of the guideline. A prior AHRQ WebM&M commentary discusses the potential pitfalls inherent to providing medical advice by telephone and strategies for minimizing patient harm in these situations.
Journal Article > Review
Diagnostic errors and reflective practice in medicine.
Mamede S, Schmidt HG, Rikers R. J Eval Clin Pract. 2007;13:138-145.
The authors discuss the relationship between diagnostic errors and doctors' ability to critically reflect on their professional reasoning.
Journal Article > Study
Minimising human error in malaria rapid diagnosis: clarity of written instructions and health worker performance.
Rennie W, Phetsouvanh R, Lupisan S, et al. Trans R Soc Trop Med Hyg. 2006;101:9-18.
The authors describe the development of an instructional protocol to increase the reliability of rapid diagnostic testing of malaria.
Cases & Commentaries
Physical Diagnosis: A Lost Art?
- Spotlight Case
- Web M&M
George R. Thompson III, MD, and Abraham Verghese, MD; August 2006
A man with paraplegia was admitted to the hospital, but the admitting physician, night float resident, and daytime team all "deferred" examination of the genital area. The patient was later discovered to have life-threatening necrotizing fasciitis of this area.
Journal Article > Review
The neurologist and patient safety.
Glick TH. Neurologist. 2005;11:140-149.
The author reviews data on errors in neurology and identifies key areas for minimizing medical error in this specialty: accurate and timely diagnosis, effective information transfer, and patient safety education.