Jump to ContentJump to Main Navigation
Show Summary Details
More options …

Diagnosis

Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / McDonald, Kathryn / Singh, Hardeep

Editorial Board: Basso , Daniela / Crock, Carmel / Croskerry, Pat / Dhaliwal, Gurpreet / Ely, John / Giannitsis, Evangelos / Katus, Hugo A. / Laposata, Michael / Lyratzopoulos, Yoryos / Maude, Jason / Newman-Toker, David / Singhal, Geeta / Sittig, Dean F. / Sonntag, Oswald / Zwaan, Laura

4 Issues per year

Online
ISSN
2194-802X
See all formats and pricing
More options …

Simulation and the diagnostic process: a pilot study of trauma and rapid response teams

Lindsay L. Juriga
  • Department of Anesthesiology, Division of Pediatric Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ David J. Murray
  • Corresponding author
  • Division of Pediatric Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ John R. Boulet
  • Research and Data Resources, Foundation for Advancement of International Medical Education and Research, Philadelphia, PA, USA
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ James J. Fehr
  • Division of Pediatric Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
Published Online: 2017-07-28 | DOI: https://doi.org/10.1515/dx-2017-0010

Abstract

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.

Keywords: diagnostic process; education; patient safety; rapid response teams; simulation; trauma teams

References

  • 1.

    National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. Washington, DC: The National Academies Press, 2015.Google Scholar

  • 2.

    Graber ML. The IOM report on improving diagnosis: new concepts. Diagnosis 2015;2:201–3.Web of ScienceGoogle Scholar

  • 3.

    Zwaan L, Schiff GD, Singh H. Advancing the research agenda for diagnostic error reduction. BMJ Qual Saf 2013;22(Suppl 2):ii52–7.Web of ScienceCrossrefPubMedGoogle Scholar

  • 4.

    Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003;78:775–80.PubMedCrossrefGoogle Scholar

  • 5.

    Custers EJ. Thirty years of illness scripts: theoretical origins and practical applications. Med Teach 2015;37:457–62.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 6.

    Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf 2013;22(Suppl 2):ii21–7.CrossrefWeb of SciencePubMedGoogle Scholar

  • 7.

    Graber ML, Kissam S, Payne VL, Meyer AN, Sorensen A, Lenfestey N, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf 2012;21:535–57.Web of ScienceCrossrefPubMedGoogle Scholar

  • 8.

    Graber ML, Wachter RM, Cassel CK. Bringing diagnosis into the quality and safety equations. J Am Med Assoc 2012;308:1211–2.CrossrefWeb of ScienceGoogle Scholar

  • 9.

    Henriksen K, Brady J. The pursuit of better diagnostic performance: a human factors perspective. BMJ Qual Saf 2013;22(Suppl 2):ii1–5.Web of SciencePubMedCrossrefGoogle Scholar

  • 10.

    Henriksen K, Kaplan H. Hindsight bias, outcome knowledge and adaptive learning. Qual Saf Health Care 2003;12(Suppl 2): ii46–50.PubMedGoogle Scholar

  • 11.

    Newman-Toker DE. A unified conceptual model for diagnostic errors: underdiagnosis, overdiagnosis, and misdiagnosis. Diagnosis (Berl) 2014;1:43–8.PubMedGoogle Scholar

  • 12.

    Singh H. Editorial: helping health care organizations to define diagnostic errors as missed opportunities in diagnosis. Jt Comm J Qual Patient Saf 2014;40:99–101.PubMedCrossrefGoogle Scholar

  • 13.

    Singh H, Giardina TD, Meyer AN, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med 2013;173:418–25.Web of ScienceCrossrefPubMedGoogle Scholar

  • 14.

    Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf 2014;23:727–31.PubMedCrossrefWeb of ScienceGoogle Scholar

  • 15.

    Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. The global burden of diagnostic errors in primary care. BMJ Qual Saf 2017;26:484–94.CrossrefWeb of SciencePubMedGoogle Scholar

  • 16.

    Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf 2015;24:103–10.Web of ScienceCrossrefPubMedGoogle Scholar

  • 17.

    Singh H, Weingart SN. Diagnostic errors in ambulatory care: dimensions and preventive strategies. Adv Health Sci Educ 2009;14(Suppl 1):57–61.Web of ScienceCrossrefGoogle Scholar

  • 18.

    Wears RL, Nemeth CP. Replacing hindsight with insight: toward better understanding of diagnostic failures. Ann Emerg Med 2007;49:206–9.PubMedCrossrefWeb of ScienceGoogle Scholar

  • 19.

    Zwaan L, Singh H. The challenges in defining and measuring diagnostic error. Diagnosis (Berl) 2015;2:97–103.PubMedGoogle Scholar

  • 20.

    Zwaan L, Thijs A, Wagner C, van der Wal G, Timmermans DR. Relating faults in diagnostic reasoning with diagnostic errors and patient harm. Acad Med 2012;87:149–56.CrossrefWeb of SciencePubMedGoogle Scholar

  • 21.

    Croskerry P. From mindless to mindful practice – cognitive bias and clinical decision making. N Engl J Med 2013;368:2445–8.CrossrefWeb of SciencePubMedGoogle Scholar

  • 22.

    Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med 2002;9:1184–204.CrossrefPubMedGoogle Scholar

  • 23.

    Elstein AS. Heuristics and biases: selected errors in clinical reasoning. Acad Med 1999;74:791–4.PubMedCrossrefGoogle Scholar

  • 24.

    Hayes MM, Chatterjee S, Schwartzstein RM. Critical thinking in critical care: five strategies to improve teaching and learning in the intensive care unit. Ann Am Thorac Soc 2017;14:569–75.PubMedCrossrefWeb of ScienceGoogle Scholar

  • 25.

    Boulet JR, Murray DJ. Simulation-based assessment in anesthesiology: requirements for practical implementation. Anesthesiology 2010;112:1041–52.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 26.

    Hunt EA, Vera K, Diener-West M, Haggerty JA, Nelson KL, Shaffner DH, et al. Delays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests. Resuscitation 2009;80:819–25.CrossrefWeb of SciencePubMedGoogle Scholar

  • 27.

    Knudson MM, Khaw L, Bullard MK, Dicker R, Cohen MJ, Staudenmayer K, et al. Trauma training in simulation: translating skills from SIM time to real time. J Trauma 2008;64:255–63; discussion 63–4.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 28.

    Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest 2008;133: 56–61.CrossrefWeb of SciencePubMedGoogle Scholar

  • 29.

    McLaughlin K, Eva KW, Norman GR. Reexamining our bias against heuristics. Adv Health Sci Educ 2014;19:457–64.CrossrefWeb of ScienceGoogle Scholar

  • 30.

    Hamilton N, Freeman BD, Woodhouse J, Ridley C, Murray D, Klingensmith ME. Team behavior during trauma resuscitation: a simulation-based performance assessment. J Grad Med Educ 2009;1:253–9.PubMedCrossrefGoogle Scholar

  • 31.

    Bonafide CP, Localio AR, Roberts KE, Nadkarni VM, Weirich CM, Keren R. Impact of rapid response system implementation on critical deterioration events in children. JAMA Pediatr 2014;168:25–33.PubMedWeb of ScienceCrossrefGoogle Scholar

  • 32.

    Murray DJ, Freeman BD, Boulet JR, Woodhouse J, Fehr JJ, Klingensmith ME. Decision making in trauma settings: simulation to improve diagnostic skills. Simul Healthc 2015;10:139–45.PubMedCrossrefWeb of ScienceGoogle Scholar

  • 33.

    Mohan D, Rosengart MR, Fischhoff B, Angus DC, Farris C, Yealy DM, et al. Testing a videogame intervention to recalibrate physician heuristics in trauma triage: study protocol for a randomized controlled trial. BMC Emerg Med 2016;16:44.PubMedWeb of ScienceCrossrefGoogle Scholar

  • 34.

    Stiegler MP, Gaba DM. Decision-making and cognitive strategies. Simul Healthc 2015;10:133–8.PubMedCrossrefGoogle Scholar

  • 35.

    Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121(5 Suppl):S2–23.CrossrefWeb of SciencePubMedGoogle Scholar

  • 36.

    Mamede S, van Gog T, van den Berge K, van Saase JL, Schmidt HG. Why do doctors make mistakes? A study of the role of salient distracting clinical features. Acad Med 2014;89:114–20.Web of SciencePubMedCrossrefGoogle Scholar

  • 37.

    Abrami PC, Bernard RM, Borokhovski E, Wade A, Surkes MA, Tamim R, et al. Instructional interventions affecting critical thinking skills and dispositions: a stage 1 meta-analysis. Rev Educ Res 2008;78:1102–34.CrossrefWeb of ScienceGoogle Scholar

  • 38.

    Issenberg SB, McGaghie WC, Hart IR, Mayer JW, Felner JM, Petrusa ER, et al. Simulation technology for health care professional skills training and assessment. J Am Med Assoc 1999;282:861–6.CrossrefGoogle Scholar

  • 39.

    Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82. Med Teach 2013;35:e1511–30.PubMedCrossrefWeb of ScienceGoogle Scholar

  • 40.

    McBride ME, Waldrop WB, Fehr JJ, Boulet JR, Murray DJ. Simulation in pediatrics: the reliability and validity of a multiscenario assessment. Pediatrics 2011;128:335–43.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 41.

    Steadman RH, Coates WC, Huang YM, Matevosian R, Larmon BR, McCullough L, et al. Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills. Crit Care Med 2006;34:151–7.PubMedCrossrefGoogle Scholar

  • 42.

    Norman G, Young M, Brooks L. Non-analytical models of clinical reasoning: the role of experience. Med Educ 2007;41:1140–5.Web of SciencePubMedGoogle Scholar

  • 43.

    Yardley S, Teunissen PW, Dornan T. Experiential learning: AMEE Guide No. 63. Med Teach 2012;34:e102–15.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 44.

    DeAnda A, Gaba DM. Role of experience in the response to simulated critical incidents. Anesth Analg 1991;72:308–15.PubMedGoogle Scholar

  • 45.

    Gilbart MK, Hutchison CR, Cusimano MD, Regehr G. A computer-based trauma simulator for teaching trauma management skills. Am J Surg 2000;179:223–8.PubMedCrossrefGoogle Scholar

  • 46.

    Boulet JR, Murray D, Kras J, Woodhouse J, McAllister J, Ziv A. Reliability and validity of a simulation-based acute care skills assessment for medical students and residents. Anesthesiology 2003;99:1270–80.CrossrefPubMedGoogle Scholar

  • 47.

    Murray DJ, Boulet JR, Avidan M, Kras JF, Henrichs B, Woodhouse J, et al. Performance of residents and anesthesiologists in a simulation-based skill assessment. Anesthesiology 2007;107:705–13.Web of ScienceCrossrefGoogle Scholar

  • 48.

    Murray DJ, Boulet JR, Kras JF, Woodhouse JA, Cox T, McAllister JD. Acute care skills in anesthesia practice: a simulation-based resident performance assessment. Anesthesiology 2004;101:1084–95.CrossrefGoogle Scholar

  • 49.

    Park CS, Stojiljkovic L, Milicic B, Lin BF, Dror IE. Training induces cognitive bias: the case of a simulation-based emergency airway curriculum. Simul Healthc 2014;9:85–93.CrossrefWeb of SciencePubMedGoogle Scholar

  • 50.

    Kaufman DM. Applying educational theory in practice. Br Med J 2003;326:213–6.CrossrefGoogle Scholar

About the article

Corresponding author: David J. Murray, Director, Wood Simulation Center, Carol B. and Jerome T. Loeb Professor, Division of Pediatric Anesthesiology, Department of Anesthesiology, Washington University School of Medicine, Box 8054, St. Louis, MO, USA, Phone: +314-457-3116, Fax: +314-454-2296


Received: 2017-02-28

Accepted: 2017-06-24

Published Online: 2017-07-28

Published in Print: 2017-11-27


Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: AHRQ: R18 HS022265-01 Murray, David John. Critical Care Management: A Simulation-Based Assessment of Decision-Making Skills. (Principle Investigator) 7/1/13-4/30/17.

AHRQ: RO1 HS018734-01, Murray [PI]. Teamwork, Communication and Decision-making: An Assessment Program Using Simulation. NIH Agency for Healthcare Research and Quality [AHRQ].

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.


Citation Information: Diagnosis, Volume 4, Issue 4, Pages 241–249, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2017-0010.

Export Citation

©2017 Walter de Gruyter GmbH, Berlin/Boston. Copyright Clearance Center

Comments (0)

Please log in or register to comment.
Log in