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Volume 4 Issue 4
Issue of
Diagnosis
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Contents
Journal Overview
Contents
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November 27, 2017
Frontmatter
Page range: i-iii
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Editorials
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November 22, 2017
Laboratory-related errors: you cannot manage what you don’t measure. You manage what you know and measure
Ada Aita, Laura Sciacovelli, Mario Plebani
Page range: 193-195
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October 5, 2017
Nurses, diagnosis and diagnostic error
Julie Considine
Page range: 197-199
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Reviews
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July 19, 2017
Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action
Kelly T. Gleason, Patricia M. Davidson, Elizabeth K. Tanner, Diana Baptiste, Cynda Rushton, Jennifer Day, Melinda Sawyer, Deborah Baker, Lori Paine, Cheryl R. Dennison Himmelfarb, David E. Newman-Toker
Page range: 201-210
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Abstract
Nurses have always been involved in the diagnostic process, but there remains a pervasive view across physicians, nurses, and allied health professionals that medical diagnosis is solely a physician responsibility. There is an urgent need to adjust this view and for nurses to take part in leading efforts addressing diagnostic errors. The purpose of this article is to define a framework for nursing engagement in the diagnostic process that can serve as a catalyst for nurses to engage in eliminating preventable harms from diagnostic error. We offer a conceptual model to formalize and expand nurses’ engagement in the diagnostic process through education, maximize effectiveness of interprofessional teamwork and communication through culture change, and leverage the nursing mission to empower patients to become active members of the diagnostic team. We describe the primary barriers, including culture, education, operations, and regulations, to nurses participating as full, equal members of the diagnostic team, and illustrate our approach to addressing these barriers. Nurses already play a major role in diagnosis and increasingly take ownership of this role, removing barriers will strengthen nurses’ ability to be equal, integral diagnostic team members. This model should serve as a foundation for increasing the role of the nurse in the diagnostic process, and calling nurses to take action in leading efforts to reduce diagnostic error.
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September 8, 2017
The impact of electronic health records on diagnosis
Mark L. Graber, Colene Byrne, Doug Johnston
Page range: 211-223
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Abstract
Diagnostic error may be the largest unaddressed patient safety concern in the United States, responsible for an estimated 40,000–80,000 deaths annually. With the electronic health record (EHR) now in near universal use, the goal of this narrative review is to synthesize evidence and opinion regarding the impact of the EHR and health care information technology (health IT) on the diagnostic process and its outcomes. We consider the many ways in which the EHR and health IT facilitate diagnosis and improve the diagnostic process, and conversely the major ways in which it is problematic, including the unintended consequences that contribute to diagnostic error and sometimes patient deaths. We conclude with a summary of suggestions for improving the safety and safe use of these resources for diagnosis in the future.
Opinion Papers
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October 5, 2017
The new diagnostic team
Mark L. Graber, Diana Rusz, Melissa L. Jones, Diana Farm-Franks, Barbara Jones, Jeannine Cyr Gluck, Dana B. Thomas, Kelly T. Gleason, Kathy Welte, Jennifer Abfalter, Marie Dotseth, Kathleen Westerhaus, Josanne Smathers, Ginny Adams, Michael Laposata, Tina Nabatchi, Margaret Compton, Quentin Eichbaum
Page range: 225-238
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Abstract
The National Academy of Medicine (NAM) in the recently issued report Improving Diagnosis in Health Care outlined eight major recommendations to improve the quality and safety of diagnosis. The #1 recommendation was to improve teamwork in the diagnostic process. This is a major departure from the classical approach, where the physician is solely responsible for diagnosis. In the new, patient-centric vision, the core team encompasses the patient, the physician and the associated nursing staff, with each playing an active role in the process. The expanded diagnostic team includes pathologists, radiologists, allied health professionals, medical librarians, and others. We review the roles that each of these team members will need to assume, and suggest “first steps” that each new team member can take to achieve this new dynamic.
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October 6, 2017
The key role of differential diagnosis in diagnosis
Bimal Jain
Page range: 239-240
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Abstract
Differential diagnosis, that is, the creation of a list of suspected diseases, is important as it guides us in looking for these diseases in a patient during diagnosis. If a disease is not included in differential diagnosis, it is not likely to be diagnosed. It is important to include uncommon as well as common diseases in differential diagnosis.
Original Articles
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July 28, 2017
Simulation and the diagnostic process: a pilot study of trauma and rapid response teams
Lindsay L. Juriga, David J. Murray, John R. Boulet, James J. Fehr
Page range: 241-249
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Background: Simulation is frequently used to recreate many of the crises encountered in patient care settings. Teams learn to manage these crises in an environment that maximizes their learning experiences and eliminates the potential for patient harm. By designing simulation scenarios that include conditions associated with diagnostic errors, teams can experience how their decisions can lead to errors. The purpose of this study was to assess how trauma teams (TrT) and pediatric rapid response teams (RRT) managed scenarios that included a diagnostic error. Methods: We developed four scenarios that would require TrT and pediatric RRT to manage an error in diagnosis. The two trauma scenarios (spinal cord injury and tracheobronchial tear) were designed to not respond to the heuristic management approach frequently used in trauma settings. The two pediatric scenarios (foreign body aspiration and coarctation of the aorta) had an incorrect diagnosis on admission. Two raters independently scored the scenarios using a rating system based on how teams managed the diagnostic process (search, establish and confirm a new diagnosis and initiate therapy based on the new diagnosis). Results: Twenty-one TrT and 17 pediatric rapid response managed 51 scenarios. All of the teams questioned the initial diagnosis. The teams were able to establish and confirm a new diagnosis in 49% of the scenarios (25 of 51). Only 23 (45%) teams changed their management of the patient based on the new diagnosis. Conclusions: Simulation can be used to recreate conditions that engage teams in the diagnostic process. In contrast to most instruction about diagnostic error, teams learn through realistic experiences and receive timely feedback about their decision-making skills. Based on the findings in this pilot study, the majority of teams would benefit from an education intervention designed to improve their diagnostic skills.
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November 21, 2017
Exploring the sources and mechanisms of cognitive errors in medical diagnosis with associative memory models
Andrés Pomi
Page range: 251-259
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Background: One of the central challenges of third millennium medicine is the abatement of medical errors. Among the most frequent and hardiest causes of misdiagnosis are cognitive errors produced by faulty medical reasoning. These errors have been analyzed from the perspectives of cognitive psychology and empirical medical studies. We introduce a neurocognitive model of medical diagnosis to address this issue. Methods: We construct a connectionist model based on the associative nature of human memory to explore the non-analytical, pattern-recognition mode of diagnosis. A context-dependent matrix memory associates signs and symptoms with their corresponding diseases. The weights of these associations depend on the frequencies of occurrence of each disease and on the different combinations of signs and symptoms of each presentation of that disease. The system receives signs and symptoms and by a second input, the degree of diagnostic uncertainty. Its output is a probabilistic map on the set of possible diseases. Results: The model reproduces different kinds of well-known cognitive errors in diagnosis. Errors in the model come from two sources. One, dependent on the knowledge stored in memory, varies with the accumulated experience of the physician and explains age-dependent errors and effects such as epidemiological masking. The other is independent of experience and explains contextual effects such as anchoring. Conclusions: Our results strongly suggest that cognitive biases are inevitable consequences of associative storage and recall. We found that this model provides valuable insight into the mechanisms of cognitive error and we hope it will prove useful in medical education.
Case Report
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November 22, 2017
Not all that vesicles is herpes
Robert R. Gruhl, Andrew Wu, Micah Niermann, Andrew Olson
Page range: 261-264
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Background: Eczema coxsackium (EC) can manifest in patients with underlying atopic dermatitis (AD) as a diffuse vesicular rash in a febrile child. The presentation overlaps clinically with the feared diagnosis of eczema herpeticum (EH), which makes differentiating between the conditions very important. Case presentation: A 6-month-old girl with known AD presented with fever and rapidly spreading vesicular rash. The patient had multiple exposures including a new antibiotic prescription, introduction of new foods, 6-month vaccinations and a sick contact. She was treated empirically with acyclovir for EH until herpes simplex virus (HSV) polymerase chain reaction (PCR) returned negative and enterovirus PCR returned positive. Once the diagnosis of EC was confirmed, antiviral therapy was discontinued and she was treated successfully with supportive measures without sequelae. Conclusions: Differentiating EC from EH is important clinically as EC is self-limiting and resolves spontaneously whereas EH may cause severe complications if not treated early. While morphology alone cannot reliably distinguish between the conditions, clinical suspicion based on history can prompt proper testing and improve patient outcomes.
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November 27, 2017
Acknowledgment
Page range: 265-265
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Congress Abstracts
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October 5, 2017
Diagnostic Error in Medicine
10th International Conference
Page range: eA43-eA124
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Journal Overview
About this journal
Objective
Diagnosis
is a subscription journal, which focuses on how diagnosis can be advanced, how it is taught, and how and why it can fail, leading to diagnostic errors. The journal welcomes both fundamental and applied works, improvement initiatives, opinions, and debates to encourage new thinking on improving this critical aspect of healthcare quality.
Diagnosis
is the official journal of the
Society to Improve Diagnosis in Medicine
.
Please submit your manuscript here
Topics
Factors that promote diagnostic quality and safety
Clinical reasoning
Diagnostic errors in medicine
The factors that contribute to diagnostic error: human factors, cognitive issues, and system-related breakdowns
Improving the value of diagnosis – eliminating waste and unnecessary testing
How culture and removing blame promote awareness of diagnostic errors
Training and education related to clinical reasoning and diagnostic skills
Advances in laboratory testing and imaging that improve diagnostic capability
Local, national and international initiatives to reduce diagnostic error
Article formats
Research Reports – Reports of original research
Short Communications – Reports of early research results and pilot studies
Reviews – Systematic, narrative, and focused reviews. Review articles are normally published by invitation, but suggestions to the Editors are welcome
Opinion Papers and Editorials
Letters to the Editor
Point/Counterpoint Papers
Guidelines and Recommendations
Innovations in diagnostic testing – Advances in laboratory testing or diagnostic imaging are appropriate subjects, or evaluations of recent innovations
Case Reports – Learning from Tragedy – Case reports of diagnostic error or dilemma discussed from a multi-stakeholder perspective; should include the facts of the case, a discussion focused on a root cause analysis, take-away points or action items resulting from the analysis, and whenever possible input from both the affected patients and their providers
Case Reports – Lessons in Clinical Reasoning: Pitfalls, Myths, and Pearls – Case reports in which a clinician discusses their diagnostic approach after clinical information is presented, focusing on a case in which a diagnostic error (or near miss = great catch) occurred
Patient-Focused Articles – Papers in this category should be written in lay language on a topic of interest to the patient stakeholder community
Diagnosis in the News – Brief reports of news-worthy advances in diagnosis, or problems involving diagnostic error
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