Refining a Framework to Enhance Communication in the Emergency Department During the Diagnostic Process: An eDelphi Approach

BACKGROUND

Emergency departments (EDs) are susceptible to diagnostic error. Suboptimal communication between the patient and the interdisciplinary care team increases risk to diagnostic safety. The role of communication remains underrepresented in existing diagnostic decision-making conceptual models.

METHODS

The authors used eDelphi methodology, whereby data are collected electronically, to achieve consensus among an expert panel of 18 clinicians, patients, family members, and other participants on a refined ED-based diagnostic decision-making framework that integrates several potential opportunities for communication to enhance diagnostic quality. This study examined the entire diagnostic process in the ED, from prehospital to discharge or transfer to inpatient care, and identified where communication breakdowns could occur. After four iterative rounds of the eDelphi process, including a final validation round by all participants, the project's a priori consensus threshold of 80% agreement was reached.

RESULTS

The authors developed a final framework that positions communication more prominently in the diagnostic process in the ED and enhances the original National Academies of Sciences, Engineering, and Medicine (NASEM) and ED-adapted NASEM frameworks. Specific points in the ED journey were identified where more attention to communication might be helpful. Two specific types of communication-information exchange and shared understanding-were identified as high priority for optimal outcomes. Ideas for communication-focused interventions to prevent diagnostic error in the ED fell into three categories: patient-facing, clinician-facing, and system-facing interventions.

CONCLUSION

This project's refinement of the NASEM framework adapted to the ED can be used to develop communications-focused interventions to reduce diagnostic error in this highly complex and error-prone setting.

Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process

OBJECTIVES

Achieving diagnostic excellence on medical wards requires teamwork and effective team dynamics. However, the study of ward team dynamics in teaching hospitals is relatively underdeveloped. We aim to enhance understanding of how ward team members interact in the diagnostic process and of the underlying behavioral, psychological, and cognitive mechanisms driving team interactions.

METHODS

We used mixed-methods to develop and refine a conceptual model of how ward team dynamics in an academic medical center influence the diagnostic process. First, we systematically searched existing literature for conceptual models and empirical studies of team dynamics. Then, we conducted field observations with thematic analysis to refine our model.

RESULTS

We present a conceptual model of how medical ward team dynamics influence the diagnostic process, which serves as a roadmap for future research and interventions in this area. We identified three underexplored areas of team dynamics that are relevant to diagnostic excellence and that merit future investigation (1): ward team structures (e.g., team roles, responsibilities) (2); contextual factors (e.g., time constraints, location of team members, culture, diversity); and (3) emergent states (shared mental models, psychological safety, team trust, and team emotions).

CONCLUSIONS

Optimizing the diagnostic process to achieve diagnostic excellence is likely to depend on addressing all of the potential barriers and facilitators to ward team dynamics presented in our model.

Bedside Clinicians' Perceptions on the Contributing Role of Diagnostic Errors in Acutely Ill Patient Presentation: A Survey of Academic and Community Practice

OBJECTIVES

This study aimed to explore clinicians' perceptions of the occurrence of and factors associated with diagnostic errors in patients evaluated during a rapid response team (RRT) activation or unplanned admission to the intensive care unit (ICU).

METHODS

A multicenter prospective survey study was conducted among multiprofessional clinicians involved in the care of patients with RRT activations and/or unplanned ICU admissions (UIAs) at 2 academic hospitals and 1 community-based hospital between April 2019 and March 2020. A study investigator screened eligible patients every day. Within 24 hours of the event, a research coordinator administered the survey to clinicians, who were asked the following: whether diagnostic errors contributed to the reason for RRT/UIA, whether any new diagnosis was made after RRT/UIA, if there were any failures to communicate the diagnosis, and if involvement of specialists earlier would have benefited that patient. Patient clinical data were extracted from the electronic health record.

RESULTS

A total of 1815 patients experienced RRT activations, and 1024 patients experienced UIA. Clinicians reported that 18.2% (95/522) of patients experienced diagnostic errors, 8.0% (42/522) experienced a failure of communication, and 16.7% (87/522) may have benefitted from earlier involvement of specialists. Compared with academic settings, clinicians in the community hospital were less likely to report diagnostic errors (7.0% versus 22.8%, P = 0.002).

CONCLUSIONS

Clinicians report a high rate of diagnostic errors in patients they evaluate during RRT or UIAs.

Crossing Academic Boundaries for Diagnostic Safety: 10 Complex Challenges and Potential Solutions From Clinical Perspectives and High-Reliability Organizing Principles

OBJECTIVE

We apply the high-reliability organization (HRO) paradigm to the diagnostic process, outlining challenges to enacting HRO principles in diagnosis and offering solutions for how diagnostic process stakeholders can overcome these barriers.

BACKGROUND

Evidence shows that healthcare is starting to organize for higher reliability by employing various principles and practices of HRO. These hold promise for enhancing safer care, but there has been little consideration of the challenges that clinicians and healthcare systems face while enacting HRO principles in the diagnostic process. To effectively deploy the HRO perspective, these barriers must be seriously considered.

METHOD

We review key principles of the HRO paradigm, the diagnostic errors and harms that potentially can be prevented by its enactment, the challenges that clinicians and healthcare systems face in executing various principles and practices, and possible solutions that clinicians and organizational leaders can take to overcome these challenges and barriers.

RESULTS

Our analyses reveal multiple challenges including the inherent diagnostic uncertainty; the lack of diagnosis-focused performance feedback; the fact that diagnosis is often a solo, rather than team, activity; the tendency to simplify the diagnostic process; and professional and institutional status hierarchies. But these challenges are not insurmountable-there are strategies and solutions available to overcome them.

CONCLUSION

The HRO lens offers some important ideas for how the safety of the diagnostic process can be improved.

APPLICATION

The ideas proposed here can be enacted by both individual clinicians and healthcare leaders; both are necessary for making systematic progress in enhancing diagnostic performance.

A clinical reasoning curriculum for medical students: an interim analysis

OBJECTIVES

Diagnostic error is a critical patient safety issue that can be addressed in part through teaching clinical reasoning. Medical schools with clinical reasoning curricula tend to emphasize general reasoning concepts (e.g., differential diagnosis generation). Few published curricula go beyond teaching the steps in the diagnostic process to address how students should structure their knowledge to optimize diagnostic performance in future clinical encounters or to discuss elements outside of individual cognition that are essential to diagnosis.

METHODS

In 2016, the University of California, San Francisco School of Medicine launched a clinical reasoning curriculum that simultaneously emphasizes reasoning concepts and intentional knowledge construction; the roles of patients, families, interprofessional colleagues; and communication in diagnosis. The curriculum features a longitudinal thread beginning in first year, with an immersive three week diagnostic reasoning (DR) course in the second year. Students evaluated the DR course. Additionally, we conducted an audit of the multiyear clinical reasoning curriculum using the Society to Improve Diagnosis in Medicine-Macy Foundation interprofessional diagnostic education competencies.

RESULTS

Students rated DR highly (range 4.13-4.18/5 between 2018 and 2020) and reported high self-efficacy with applying clinical reasoning concepts and communicating reasoning to supervisors. A course audit demonstrated a disproportionate emphasis on individual (cognitive) competencies with inadequate attention to systems and team factors in diagnosis.

CONCLUSIONS

Our clinical reasoning curriculum led to high student self-efficacy. However, we stressed cognitive aspects of reasoning with limited instruction on teams and systems. Diagnosis education should expand beyond the cognitive- and physician-centric focus of most published reasoning courses.

A Research Agenda for Diagnostic Excellence in Critical Care Medicine

Diagnosing critically ill patients in the intensive care unit is difficult. As a result, diagnostic errors in the intensive care unit are common and have been shown to cause harm. Research to improve diagnosis in critical care medicine has accelerated in past years. However, much work remains to fully elucidate the diagnostic process in critical care. To achieve diagnostic excellence, interdisciplinary research is needed, adopting a balanced strategy of continued biomedical discovery while addressing the complex care delivery systems underpinning the diagnosis of critical illness.

A novel framework to guide antibiotic stewardship nursing practice

BACKGROUND

There is a pervasive view among some nurses and health care disciplines that antibiotic stewardship (AS) is solely a physician or pharmacist responsibility. There is an urgent need to alter this view so that nurses can seize every opportunity to prevent patient harm from antibiotics and optimize antibiotic use. One challenge to achieving full nurse engagement as equal members of the AS team is lack of an organizing framework to illustrate relationships of phenomena and concepts inherent to adoption of AS nursing practices.

METHODS

We sought to create a framework derived from the peer-reviewed literature, systematic and scoping reviews, and professional standards, consensus statements and white papers. The emerging framework went through multiple iterations as it was vetted with nurse clinicians, scholars and educators, physicians, pharmacists, infection preventionists and AS subject matter experts.

RESULTS

Our evidence-based Antibiotic Stewardship Nursing Practice SCAN-P Framework provides the much-needed context and clarity to help guide local-level nurses to participate in and lead AS nursing practice.

CONCLUSIONS

Nurses worldwide are ideally situated to provide holistic person-centered care, advocate for judicious use of antibiotics to minimize antibiotic resistance, and be AS educators of their patients, communities and the general public. The Antibiotic Stewardship Nursing Practice SCAN-P Framework provides a tool to do so.

A call to action: next steps to advance diagnosis education in the health professions

OBJECTIVES

Improving diagnosis-related education in the health professions has great potential to improve the quality and safety of diagnosis in practice. Twelve key diagnostic competencies have been delineated through a previous initiative. The objective of this project was to identify the next steps necessary for these to be incorporated broadly in education and training across the health professions.

METHODS

We focused on medicine, nursing, and pharmacy as examples. A literature review was conducted to survey the state of diagnosis education in these fields, and a consensus group was convened to specify next steps, using formal approaches to rank suggestions.

RESULTS

The literature review confirmed initial but insufficient progress towards addressing diagnosis-related education. By consensus, we identified the next steps necessary to advance diagnosis education, and five required elements relevant to every profession: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis.

CONCLUSIONS

The primary stakeholders, representing education, certification, accreditation, and licensure, in each profession must now take action in their own areas to encourage, promote, and enable improved diagnosis, and move these recommendations forward.

Evidence That Nurses Need to Participate in Diagnosis: Lessons From Malpractice Claims

OBJECTIVES

There is a pressing need for nurses to contribute as equals to the diagnostic process. The purpose of this article is twofold: (a) to describe the contributing factors in diagnosis-related and failure-to-monitor malpractice claims in which nurses are named the primary responsible party and (b) to describe actions healthcare leaders can take to enhance the role of nurses in diagnosis.

METHODS

We conducted a review of the Controlled Risk Insurance Company Strategies' repository of malpractice claims, which contain approximately 30% of United States claims. We analyzed the malpractice claims related to diagnosis (n = 139) and physiologic monitoring (n = 647) naming nurses as the primary responsible party from 2007 to 2016. We used logistic regression to determine the association of contributing factors to likelihood of death, indemnity, and expenses incurred.

RESULTS

Diagnosis-related cases listing communication among providers as a contributing factor were associated with a significantly higher likelihood of death (odds ratio [OR] = 3.01, 95% confidence interval [CI] = 1.50-6.03). Physiologic monitoring cases listing communication among providers as a contributing factor were associated with significantly higher likelihood of death (OR = 2.21, 95% CI = 1.49-3.27), higher indemnity incurred (U.S. $86,781, 95% CI = $18,058-$175,505), and higher expenses incurred (U.S. $20,575, 95% CI = $3685-$37,465).

CONCLUSIONS

Nurses are held legally accountable for their role in diagnosis. Raising system-wide awareness of the critical role and responsibility of nurses in the diagnostic process and enhancing nurses' knowledge and skill to fulfill those responsibilities are essential to improving diagnosis.

The critical need for nursing education to address the diagnostic process

Diagnostic errors are among the most common medical errors and the deadliest. The National Academy of Medicine recently concluded that diagnostic errors represent an urgent national concern. Their first recommendation to address this issue called for promoting the key role of the nurse in the diagnostic process. Registered nurses across clinical settings significantly contribute to the medical diagnostic process, though their role in diagnosis has historically gone unacknowledged. In this paper, we review the history and current state of diagnostic education in pre-licensure registered nurse preparation, introduce interprofessional individual- and team-based competencies to improve diagnostic safety, and discuss the next steps for nursing education. Nurses educated and empowered to fully participate in the diagnostic process are essential for achieving better, safer patient outcomes.

Competencies for improving diagnosis: an interprofessional framework for education and training in health care

Background Given an unacceptably high incidence of diagnostic errors, we sought to identify the key competencies that should be considered for inclusion in health professions education programs to improve the quality and safety of diagnosis in clinical practice. Methods An interprofessional group reviewed existing competency expectations for multiple health professions, and conducted a search that explored quality, safety, and competency in diagnosis. An iterative series of group discussions and concept prioritization was used to derive a final set of competencies. Results Twelve competencies were identified: Six of these are individual competencies: The first four (#1-#4) focus on acquiring the key information needed for diagnosis and formulating an appropriate, prioritized differential diagnosis; individual competency #5 is taking advantage of second opinions, decision support, and checklists; and #6 is using reflection and critical thinking to improve diagnostic performance. Three competencies focus on teamwork: Involving the patient and family (#1) and all relevant health professionals (#2) in the diagnostic process; and (#3) ensuring safe transitions of care and handoffs, and "closing the loop" on test result communication. The final three competencies emphasize system-related aspects of care: (#1) Understanding how human-factor elements influence the diagnostic process; (#2) developing a supportive culture; and (#3) reporting and disclosing diagnostic errors that are recognized, and learning from both successful diagnosis and from diagnostic errors. Conclusions These newly defined competencies are relevant to all health professions education programs and should be incorporated into educational programs.

Reducing delays to diagnosis in ambulatory care settings: A macrocognition perspective

We aim to use a macrocognition theoretical perspective to characterize contributors to diagnostic delays by physicians that can be mitigated by work system redesign. As experienced with other complex, sociotechnical domains, system redesign is anticipated to be more effective at improving safety than training-based solutions. In the outpatient care setting, complex tasks, conducted by a primary care provider, are provided for five macrocognition functions: sensemaking, re-planning, detecting problems, deciding, and coordinating. Redesigning systems could reduce delays to diagnosis by helping users to avoid missed symptoms, forgotten follow-up activities, and delayed actions. Health information technology could support resilience strategies by offloading documentation burdens, recording working diagnoses, displaying planned follow-up activities at the correct time interval, and supporting recognition of patterns in patient care. These insights suggest a path forward for future research on system design innovations to reduce diagnostic delays, and ultimately, reduce patient harm.

Serious misdiagnosis-related harms in malpractice claims: The “Big Three” – vascular events, infections, and cancers

Background

Diagnostic errors cause substantial preventable harm, but national estimates vary widely from 40,000 to 4 million annually. This cross-sectional analysis of a large medical malpractice claims database was the first phase of a three-phase project to estimate the US burden of serious misdiagnosis-related harms.

Methods

We sought to identify diseases accounting for the majority of serious misdiagnosis-related harms (morbidity/mortality). Diagnostic error cases were identified from Controlled Risk Insurance Company (CRICO)’s Comparative Benchmarking System (CBS) database (2006–2015), representing 28.7% of all US malpractice claims. Diseases were grouped according to the Agency for Healthcare Research and Quality (AHRQ) Clinical Classifications Software (CCS) that aggregates the International Classification of Diseases diagnostic codes into clinically sensible groupings. We analyzed vascular events, infections, and cancers (the “Big Three”), including frequency, severity, and settings. High-severity (serious) harms were defined by scores of 6–9 (serious, permanent disability, or death) on the National Association of Insurance Commissioners (NAIC) Severity of Injury Scale.

Results

From 55,377 closed claims, we analyzed 11,592 diagnostic error cases [median age 49, interquartile range (IQR) 36–60; 51.7% female]. These included 7379 with high-severity harms (53.0% death). The Big Three diseases accounted for 74.1% of high-severity cases (vascular events 22.8%, infections 13.5%, and cancers 37.8%). In aggregate, the top five from each category (n = 15 diseases) accounted for 47.1% of high-severity cases. The most frequent disease in each category, respectively, was stroke, sepsis, and lung cancer. Causes were disproportionately clinical judgment factors (85.7%) across categories (range 82.0–88.8%).

Conclusions

The Big Three diseases account for about three-fourths of serious misdiagnosis-related harms. Initial efforts to improve diagnosis should focus on vascular events, infections, and cancers.

What interventions could reduce diagnostic error in emergency departments? A review of evidence, practice and consumer perspectives

The purpose of this article is to synthesise review evidence, practice and patient perspectives on interventions to reduce diagnostic error in emergency departments (EDs). A rapid review methodology identified nine systematic reviews for inclusion. Six practice interviews were conducted to identify local contextual insights and implementation considerations. Finally, patient perspectives were explored through a citizen panel with 11 participants. The rapid review found evidence for the following interventions: second opinion, decision aids, guided reflection and education. Practitioners suggested three of the four interventions from the academic review: second opinion, decision aids and education. Practitioners suggested four additional interventions: improving teamwork, engaging patients, learning from mistakes and scheduled test follow-up. Patients most favoured interventions that improved communication through education and patient engagement, while also suggesting that implementation of state-wide standards to reduce variability in care and sufficient staffing are important to address diagnostic errors. Triangulating these three perspectives on the evidence allows for the intersections to be highlighted and demonstrates the usefulness of incorporating practitioner reflections and patient values in developing potential interventions.

The final assessment and its association with field assessment in patients who were transported by the emergency medical service

Background

In patients who call for the emergency medical service (EMS), there is a knowledge gap with regard to the final assessment after arriving at hospital and its association with field assessment.

Aim

In a representative population of patients who call for the EMS, to describe a) the final assessment at hospital discharge and b) the association between the assessment in the field and the assessment at hospital discharge.

Methods

Thirty randomly selected patients reached by a dispatched ambulance each month between 1 Jan and 31 Dec 2016 in one urban, one rural and one mixed ambulance organisation in Sweden took part in the study. The exclusion criteria were age < 18 years, dead on arrival, transport between health-care facilities and secondary missions. Each patient received a unique code based on the ICD code at hospital discharge and field assessment.

Results

In all, 1080 patients took part in the study, of which 1076 (99.6%) had a field assessment code. A total of 894 patients (83%) were brought to a hospital and an ICD code (ICD-10-SE) was available in 814 patients (91% of these cases and 76% of all cases included in the study). According to these ICD codes, the most frequent conditions were infection (15%), trauma (15%) and vascular disease (9%). The most frequent body localisation of the condition was the thorax (24%), head (16%) and abdomen (13%). In 118 patients (14% of all ICD codes), the condition according to the ICD code was judged as time critical. Among these cases, field assessment was assessed as potentially appropriate in 75% and potentially inappropriate in 12%.

Conclusion

Among patients reached by ambulance in Sweden, 83% were transported to hospital and, among them, 14% had a time-critical condition. In these cases, the majority were assessed in the field as potentially appropriate, but 12% had a potentially inappropriate field assessment. The consequences of these findings need to be further explored.

Electronic supplementary material

The online version of this article (10.1186/s13049-018-0579-x) contains supplementary material, which is available to authorized users.

Improving diagnosis by improving education: a policy brief on education in healthcare professions

Diagnostic error is increasingly recognized as a major patient safety concern. Efforts to improve diagnosis have largely focused on safety and quality improvement initiatives that patients, providers, and health care organizations can take to improve the diagnostic process and its outcomes. This educational policy brief presents an alternative strategy for improving diagnosis, centered on future healthcare providers, to improve the education and training of clinicians in every health care profession. The hypothesis is that we can improve diagnosis by improving education. A literature search was first conducted to understand the relationship of education and training to diagnosis and diagnostic error in different health care professions. Based on the findings from this search we present the justification for focusing on education and training, recommendations for specific content that should be incorporated to improve diagnosis, and recommendations on educational approaches that should be used. Using an iterative, consensus-based process, we then developed a driver diagram that categorizes the key content into five areas. Learners should: 1) Acquire and effectively use a relevant knowledge base, 2) Optimize clinical reasoning to reduce cognitive error, 3) Understand system-related aspects of care, 4) Effectively engage patients and the diagnostic team, and 5) Acquire appropriate perspectives and attitudes about diagnosis. These domains echo recommendations in the National Academy of Medicine’s report Improving Diagnosis in Health Care. The National Academy report suggests that true interprofessional education and training, incorporating recent advances in understanding diagnostic error, and improving clinical reasoning and other aspects of education, can ultimately improve diagnosis by improving the knowledge, skills, and attitudes of all health care professionals.