Patient Safety

Compare and contrast "fluid" teams and "fixed" teams in terms of personnel, environment, advantages and disadvantages.

- Fixed team - working with same group Advantage: get use to one another, use to communicating with one another Disadvantage: people will work sloppier, suffer from groupthink - Fluid teams (way more common) - working with different people, never same people; put speed and novelty and better when there is more uncertainty. The ER Is best explanation of a fluid team. Advantage: a lot of introductions, Disadvantage: not feeling comfortable with one another, not knowing how one works

List the "five dimensions of safety" and provide an example of how each dimension is assessed. (pg. 30-31)

- Harm - case record review - Reliability - observation of safety critical behavior - Sensitivity to operations - Safety walk-round and conservations - Anticipation and preparedness - Structural reflection - Integration and learning - Aggregate analysis of incidents and complaints

1) Discuss the different settings/locations in which errors are made.

- Hospitals - Pharmacies - Care clinics (physicians' offices) - Patients' homes - Home Health - Ambulatory Settings (walk into clinic and can be seen) (not being carried in) - Administration (process of transportation) - Lab - Nursing homes

1. When you consider all the individuals involved in a patient's care, who carries the most responsibility in ensuring each of the 6 aims are met? Who carries the least? Explain your answers.

- I believe everyone has a big part in it, nurses have a lot of direct contact with patients, so I believe they carry the most responsibility. The one who carries the least I would say is the patient.

What do you believe are barriers to healthcare professionals' use of the most effective care known?

- Lack of knowledge, access to the equipment, lack of funding, over worked and under- staffed, location, insurance (what they will pay for or what they won't pay for) - Potential conflict between the aims of patient of patient-centeredness and effectiveness, and the need to balance the aim of equity as applied to the population with achievement of the other aims at the level of the individual

Discuss three strategies medical schools and healthcare could use to improve cognitive ability in physicians.

- Learning from mistakes and get a better insight on clinical reasoning. Teaching trainees about not judging off things that has happened in the past with other patients, but to try and diagnose the patient that is in front of you by the best of your ability. Also, there should be feedback given from trainees to physician. Requiring doctors to slow down and not just tell a patient "oh you're just having real bad ..." without first going through their checklist to help properly diagnose a patient.

Identify and discuss three of the barriers to improving quality and safety of care, according to the authors of the Johnson text.

- Medical errors - Patient Harms - Present lack of clinician engagement

Give some examples of type of errors that are made in healthcare.

- Medication errors - Medical record errors / chart error / entering in data - Errors related to anesthesia/drug related incidents/ incorrect dosages - Hospital acquired infections - Missed or delayed diagnosis / lack of knowledge - Communication errors - Surgical errors - Diagnostic error - massive

In the 21st century, teamwork is imperative for the success of healthcare. Discuss the historical changes that have transpired in the last 50 years that have led to an increased need for teamwork in healthcare.

- New medications and procedures - Technology is more complex - Large numbers of procedures and more options available for medication. - The number of patients we have now is exploding and they are living longer. - The need for specialist. - New professions (jobs)

Discuss the difference between conscious behavior and automatic behavior, and how slips and mistakes fit into these two concepts. Provide an example of a slip, and a mistake.

- Conscious behavior is what we do when we "pay attention" to a task, like when you are learning something new. - Automatic behavior is when we do things unconsciously. It is something we had to learn at first but after you do it so many times you can do it in your sleep. It takes less energy and slips. - (pg.25) Example of a slip: took the patients vitals but forgot to record it - Example of a mistake: providing the wrong diagnosis to a patient

Discuss two strategies a healthcare organization can use to empower their employees to communicate effectively, particularly when there is a safety issue. Pg.166

- Consider using certain phrases and words to communicate other professionals: - SBR: used a tool for nurses to communicate, get along better, and make sure information that is needed to get communicated - CUS: concern - - I pass the baton - making sure that communication is getting passed to one another

Define "overdiagnosis". What factors in our world have led to this phenomenon? Why is it dangerous for patients?

- Detection of abnormalities that will never cause symptoms or death during a patient lifetime if left alone. - Causes unnecessary stress

Error

an act of commissions (doing something wrong) or omissions (failing to do the right thing) leading to na undesirable outcome or significant potential for such an outcome SYN. - mistake

"Near Misses"

error that is made but does not result in an adverse event (ex: bullet that is missed) SYN. - "close calls"

Adverse events

unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization, or that results in death SYN. - harm

Discuss the term "pay-for-performance". List two examples of P4P models/programs. What are the advantages and disadvantages of these strategies?

"Pay-for-performance" - paying doctors for quality performance from insurance companies. We are not going to pay for things to be done when it is not necessary (performance based payment system) -Example 1: MACRA (pg. 46) -Example 2: Value-based purchasing (pg.46) -Advantages: being utilized to motivate improvement (being more for than just showing up for the job) -Disadvantages: could compromise a provider's commitment to quality

Define "value". How does value intersect (both positively and negatively) with the concepts of "quality" and "safety"?

"Value" - what you are getting out of it for what you are paying for - Value is quality divided by cost. Value is intersected when it comes to quantity based off what someone can afford. - intersect with safety: if you're not providing safety to your patient then you patient isn't going to want to pay or feel safe - In healthcare, we want highest quality of care for the least amount of money

Define the word "competency". What does it mean to be competent? How does competency intersect with the concept of "professionalism"?

- Ability to do something successfully or efficiently - Having the necessary ability, knowledge, or skill to do something successfully - Being competence in a professionalism field. Ethical and practicing with integrity. Almost all different professions have codes of ethics. Competency can be measured more than professionalism can.

Define and discuss each of the following aspects of the diagnostic process: diagnostic uncertainty, time, population trends, diversity/health disparities, mental health.

- Diagnostic uncertainty: decision to begin treatment and if it is the right one, not knowing if diagnosis is right, will the treatment help or make it worse. - Time: must make the diagnosis in time - Population trends: we have more people aging and visiting the healthcare system with many symptoms and problems - Diversity/health disparities: different language and communication, trust/cultural issues - Mental health: you can't do physical test to diagnose a mental health, you have to observe the patient

Define the terms 'error' and 'adverse event'. How are the two similar? How are they different?

- Error- (preventable adverse events) / the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. (not every error leads to an adverse event.. called "near miss") - Adverse event- (injuries caused by medical management) / an injury caused by medical management rather than the underlying condition of the patient. (not every adverse event is from errors) - Similarities: They are both unplanned events that are not good and should be avoided. Both could result in patient mortality (death - Differences: Adverse events is care that falls below what the standards are expected of physicians. Errors is something that results in something bad usually. Error was the product and adverse event is the outcome from the error.

What are the main steps in the diagnostic process? Who are the individuals involved in the process, and what are their roles? (pg.33)

- First, a patient experiences a health problem. The patient is likely the first person to consider his or her symptoms and may choose at this point to engage with the health care system. Once a patient seeks health care, there is an iterative process of information gathering, information integration and interpretation, and determining a working diagnosis. Performing a clinical history and interview, conducting a physical exam, performing diagnostic testing, and referring or consulting with other clinicians are all ways of accumulating information that may be relevant to understanding a patient's health problem. The information-gathering approaches can be employed at different times, and diagnostic information can be obtained in different orders. Then treat it. The continuous process of information gathering, integration, and interpretation involves hypothesis generation and updating prior probabilities as more information is learned. Communication among health care professionals, the patient, and the patient's family members is critical in this cycle of information gathering, integration, and interpretation - Pharmacy involved, outpatient rehab center, patient, anybody

Briefly describe "complexity theory" and the three categories of decisions/problems therein. Why is it helpful/important to consider these categories when we look to solve the problems in healthcare?

- Complexity theory - divides decisions and problems into three categories. 1) Simple (checklist) - inputs and outputs are known. 2) Complicated - substantial uncertainties; solution may be unknown but can be known 3) Complex - formula to success is unknowable; they bear the highest level of risk - We need to match our approaches to the types at and. If we assess the wrong ones, it could cause more harm than good.

What does the acronym CPOE stand for? Briefly define/describe CPOE (pg.59)

- Computerized Provider Order Entry - Electronic prescribing - nothing has to be handwritten (in hope to reduce medical errors)

What factors have led to increased complexity in medications prescribing and administering?

- Computerized decision and support misunderstanding abbreviations. - The role of CPOE, electronic prescribing, computerized decision support, and bar coding and/or radio-frequency identification - Five rights (right patient, right route, right dose, right time, and right drug) for administering - Records transfer issues - More chronic illness, patient aged, etc. - Growth of medications, adverse events (reactions), medicine resistance, taking multiple medications

Discuss why it is difficult to identify and enumerate adverse events in healthcare.

- Lack of knowledge and studies about the events. Different definitions and assessment methods involved various studies show differing rates of adverse events. Lack of agreement and error. Hard to pinpoint what really is happening/happened to each patient because every patient is different. Shame and stigma - can be very challenging to come forward with a mistake.

List and describe the five core competencies needed for all healthcare professionals, as suggested in the report. Of the five, which is the most all-encompassing?

*Provide patient centered care - identify, respect, and care about patients differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health. *Work in interdisciplinary teams - cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable. *Employ evidence-based practice - integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible *Apply quality improvement - identify errors and hazards in care; understand and implement basic safety design principles, such as standardization and simplification; continually understand and measure quality of care in terms of structure, process, and outcomes in relation to patient and community needs; design and test interventions to change processes and systems of care, with the objective of improving quality. *Utilize informatics - communicate, manage knowledge, mitigate error, and support decision making using information technology.

Define "evidence-based practice". Provide an example of an evidence-based guideline used in healthcare. What are some of the advantages and disadvantages to reporting or using evidence-based guidelines/data as a quality measure?

- "Evidence-based practice" - practice based on research outcomes; no guideline that is being followed 100% - Example: diabetic patients research - Advantages: Care will be up to date with latest practice and research - Disadvantages: Length of time and difficulty of finding valid evidence

Define "sharp end" errors and "blunt end" errors. What are some synonyms for these terms? Which type of error is more dangerous in your opinion, and why do you think that?

- "Sharp end" (active error) - rarely enough to cause harm and must penetrate multiple incomplete layers of protection to cause devastating results. - "Blunt end" (latent error) - the proximate cause that is often an act committed or neglected by a caregiver - I would say a "sharp end" error is more dangerous because it harms more things in the process once completed.

Discuss the components of the Joint Commission's "Universal Protocol for Preventing Wrong-Site, Wrong-Procedure, Wrong-Person Surgery".

- (Table 5-20 pg. 84-85) - The protocol acknowledges that single solutions to this problem are destined to fail, and that robust fixes depend on multiple overlapping layers of protection - Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site. - Mark procedure site

Take these 6 specific aims and rank them in order of most important to least important, based on your personal opinion. Explain what led you to rank them in that order.

- 1) patient-centered - 2) safe - 3) effective - 4) equitable - 5) timely - 6) efficient - In OT the patient's comfort, and healing is the most important thing. Taking time on your patients is import in my personal opinion

Define 'active error' and 'latent error'. How are they similar? How are they different? Which one is more dangerous, in your opinion?

- Active error - occurs at the level of frontline operator, and their effects are felt almost immediately. This is sometimes called the sharp end. - Latent error - tend to be removed from the direct control of the operator and include things such as poor design, incorrect installation, faculty maintenance, bad management decisions, and poorly structured organizations. These are called the blunt end. - Similarities: They are both errors. They both can have drastic outcomes - Differences: Active errors have immediate consequences at the frontline operator, and latent errors may be difficult for people to notice since the errors maybe hidden in the design of routine. - Most dangerous: Latent error, because sometimes you are not able to see the error until it's too late.

List three cognitive biases and provide an example of each. For each bias, briefly suggest a strategy that can help combat or reduce the bias.

- Anchoring - "premature closure" relying on initial impression **must take in consideration all data new and old or get other opinions - Availability heuristics - judging by ease of recalling past cases **have legitimate stats on each patient - Blind obedience - showing undue difference to authority **reconsider when authority is more remote

Define "authority gradient" and "hierarchy". In a typical healthcare organization, describe the authority gradient and hierarchy.

- Authority gradient - is psychological difference between worker and supervisor, is relational aspect between employees that work for the top of the pyramid. Like 2 supervisors who oversees everyone. - Hierarchy - level of rank, steepness of authority agreement - main person in charge like CEO and physician

Give some examples of data sources used to estimate the incidence of diagnostic errors. What are the pros and cons of each type of data source?

- Autopsy - very through and look backwards at what caused that death and find errors if they occurred. Great source of data but don't want to die to get it Pro: find any errors and test for all things Con: patient must be dead - Medical records - allows you to see the patients has seen, and other medications and whatever they have seen in their past Pro: good way to keep up with test on patients and analysis diagnostic errors Con: might be missing information - Survey of patients - tell us about your care Pro: Patients side of the story, get how they are feeling Con: May not be completely accurate

List one of the many principles of patient safety improvement strategies and discuss what type(s) of error(s) it is most suited to address. (pg. 28-30)

- Building in redundancies and cross checks - in the form of checklists, read backs, and other standardized safety practices - Is the type of strategies that helps like check sheets and stuff - Slips errors - Simple not very complexed - Communication between other workers - Learn from one's mistakes - where errors can be openly discussed in hopes of not committing that mistake again

Regarding the case study presented on pages 54-55 of the Report ("Maureen Waters, January 2002"), what aspects of this 'utopia' scenario does healthcare have in place now, 15+ years after the Report was published? What aspects are still falling short?

- I feel effectiveness could've been better if instead of the physician relying on the patient to read their paperwork and questions, they should've gone through everything with her thoroughly, in terms of questionable health literacy. - Technology - Having a doctor who really cared and showed he care for her. (compassion and caring) - Mychart - to schedule appointments, and see all patient portal stuff

What are the three elements required for a fire to occur? How are surgical fires typically prevented?

- Ignition source (such as electrocautery and lasers) - Fuel source (gauze, drapes, even endotracheal tubes) - Oxidizers (usually oxygen but some time nitrous oxide) - A series of prevention maneuvers has been recommended, addressing all three elements of the triangle. They include the following: ignition sources should be stored away from the patients and their tips should be visualized while hot, time should allow for alcohol-based prep solutions to dry prior to draping patients, oxygen concentrations should be kept to the lowest safe amount, and cautery around the airway should be used sparingly and only after the anesthesiologist is warned so that he or she can turn down the oxygen.

Although we were introduced to the concept of "heuristics" in the chapter on diagnostic errors and physicians' cognitive abilities, in the context of HFE, heuristic analysis is a little bit different. Briefly describe three principles in heuristic analysis in the field of HFE.

- In heuristic evaluations, the usability of a particular system or device is assessed by applying established design fundamentals such as visibility of system status, user control, and freedom, consistency and standards, flexibility, and efficiency of use. pg.126 - User control and freedom - Help and Documentation - Consistency and standards - Error recovery - Flexibility and efficiency of use

Communication errors and breakdowns can be all or part of the reason a diagnostic error occurs. List the two main types of communication breakdowns that lead to diagnostic error, and provide an example of each breakdown.

- Interpersonal - exchange of information between individual - Informational - processing and management of data

Describe the field of "human factors engineering". Even though we don't often think of engineering when we think of health care, what are some HFE concepts that directly intersect and apply to healthcare?

- It is an applied science of systems design that is concerned with the interplay between humans, machines, and their work environments. Forcing functions make users stop and go through all information before acting. It sees humans' overestimate their abilities and underestimate their weakness. This tries to make up for it. - Pg. 123 - particular emphasis on the design and use of devices such as IV pumps, catheters, computer software, and hardware; device design and use - Forcing function - connecting of two things that - Watcher observing - making choices off what they observe and looking at the healthcare system as a whole

What do the authors mean by 'overdiagnosis' and 'underdiagnosis'? What implications result from each, on the patients, on health care in general?

- Overdiagnosis - when a condition is diagnosed that would otherwise not go on to cause symptoms or death. Tend to treat you for the condition and more money is spent, healthcare and more harm than good. - Underdiagnosis- not enough research is done to come to a correct diagnosis. More time more tests and more money. People start missing their jobs.

List and describe the competency domains suggested by the Johnson text authors.

- Patient Care - Knowledge for Practice - Practice-based learning and practice - Interpersonal and Communication skills - Professionalism - Systems-Based Practice - Interprofessional Collaboration - Personal and Professional Development

Define patient safety in your own words.

- Patient centered care - Prevention - Educational - I feel as if the easiest way to describe patient safety is that hospitals along with other healthcare organizations keep their patient safe from errors, injuries, and sicknesses.

What are the two main types of handoffs/transitions in health care? Provide 1 example of each type of handoff/transition.

- Patient related (anytime a patient is moving about) - patient referred from primary care provider to subspecialty consultant - Provider related (stationary) - patients are stationary during nurse change shifts

1. List the 6 specific aims (will be on test) to improve healthcare delivery, as proposed by the authors of the Report. For your chosen future career path, how do you think each of those aims should/could look in your everyday practice?

- Patient-centered, Safe, Effective, Equitable, Timely, Efficient *Safe: avoiding injuries to patients from the care that is intended to help them - In OT: be gentle with patients and do therapy in a safe environment *Effective: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse) - In OT: look at charts, use appropriate therapy for patients and do not do unnecessary treatment. Talk to patients and staff *Patient-centered: providing care that is respectful of and responsive to individual patient references, needs, and values, and ensuring that patient values guide all clinical decisions - In OT: talk to patient about what they want to achieve out of the therapy *Timely: reducing waits and sometimes harmful delays for those who receive and those who give care - In OT: make therapy move smoothly and efficient schedule appointments wisely *Efficient: avoiding waste, in particular waste of equipment, supplies, ideas, and energy - In OT: think smart on techniques for patients, do not use anything that is not necessary, don't waste time on patients that don't want to go through with therapy * Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status - In OT: not discriminating against anyone, being culturally competent, and taking job seriously enough to put aside any judgment there may be to help your patient.

Aviation is often cited as a field where errors are rare, and many in healthcare seek to apply some of the same principles to improve quality of care. Briefly describe three concepts/principles that originated in aviation, and how they might be applied in a healthcare setting to improve handoffs/transitions. Table on pg. 141-142

- Predicting and planning - Checklists - ensuring everything is done - Task allocation - everyone has their job in advance - Leadership - command responsibility - Review meetings - regular team meeting to review events - Task sequence - there is a clear order to events - Discipline and composure - communication strategies used to ensure a calm and organized atmosphere

Define the terms 'slip', 'lapse', and 'mistake'. Which one is the most dangerous, in your opinion? Why do you think that?

- Slip - observable /action conducted is not what was intended (can be thought of as actions not carried out as planned or intended) - Lapse - not observable / action conducted is not what was intended (not being able to recall a mistake) - Mistake - actions proceed as planned but fails to achieve its intended outcome because the planned action was wrong Most dangerous: Lapse because it is not observable

Explain why blaming individuals when an error or adverse event occurs is sometimes counterproductive. Why do most errors occur?

- Sometimes isn't always a person's fault - Pointing fingers will not solve the error - As a healthcare worker it is always important to take full responsibility for your errors/mistakes. Blaming someone else can cause that person to feel attacked and the person that caused the event may feel bad and be nervous to treat someone ever again. - No one is perfect. Errors are easily made when not paying close attention to what you are doing or maybe someone just doesn't know that they are causing a mistake/error, and no one has told them. Errors can occur from technology, machine errors, and maybe even multiple errors that have happened over time.

List strategies to decrease medication and discuss how each strategy works. What are some advantages and disadvantages of each strategy?

- Standardization and decreasing ambiguity: using CPOEs and using less abbreviations in computerized systems - Vigilance and the "Five Rights" of medication administration (listed above) - Double-checks: within communication, administration, everything - Preventing interruptions and distractions: one job at a time (prevent errors, but not practical) - Unit dosing: refers to the packaging of medications in ready-to-use units that are prepared in the pharmacy and then delivered to the clinical floor - Removal of medications from certain settings - The use of clinical pharmacists (one of the most powerful) (costly) - Meeting the challenge of look-alike, sound-alike medications - Medication reconciliation: process of reviewing a patient's complete medication regimen on both ends of a care transition in an effort to avoid unintended inconsistencies - Conservative prescribing: thinking past just prescribing medications and looking at other forms of treatment

Describe the three components of "Donabedian's Triad", often used to measure the quality of healthcare delivered. What are some of the advantages and disadvantages of using the triad?

- Structure - how care was organized **Advantages: may be highly relevant in a complex health system **Disadvantages: May fail to capture the quality of care by individual physicians - Process - what was done (actions) **Advantages: More easily measured and acted upon than outcomes **Disadvantages: A proxy for outcomes - Outcome - result of what happened to the patient **Advantages: What we really care about **Disadvantages: May take years to occur

Describe some of the strategies used to prevent retention of sponges and other surgical instruments. In your opinion, which strategy would work best?

- Surgical sponges with an embedded radiopaque thread meant to show up on x-rays - Attach sponges to the rings at the end and then count the rings - "Sponge, sharp, and instrument counts" - In my opinion, I feel that the count procedure would work best because you can always double check yourself by counting out the sponges.

Discuss two strategies a healthcare organization can use to improve teamwork.

- The debriefing, all team members discuss what is right and wrong after a procedure. Learn from mistakes and give snaps to what was good - Huddle meetings - talk about what Is going well and what needs to be worked on. - Introductory session on front end - Leader of team introduces self and other team members introduce their selves to make sure there is a level of comfort - Practice - working as a team takes practice, and learning of communication strategies with other team members

What is the definition of diagnostic error, formulated by the committee who wrote the report? Briefly discuss the 3 main categories of diagnostic errors.

- The failure to (a) establish an accurate and timely explanation of the patient's health problem(s) or (b) communicate that explanation to the patient. 1) no fault errors factors outside the control of the clinicians or healthcare 2) system related errors - some technology available at the particular office. 3) cognitive errors - mainly for clinician who has a lack of knowledge.

List the 4 key aspects of healthcare delivery that help explain the quality problems we have. Provide an example or description of each aspect.

- The growing complexity of science and technology (and knowledge) *EX: biomedical research - The increase in chronic conditions *EX: People are living longer and contracting more chronic illness that can be managed - A poorly organized delivery system *EX: US healthcare system, disorganization, medical errors, bad communication - Constraints on exploiting the revolution in information technology *EX: people self-diagnosing via the internet and trying to treat themselves (electronic health records, being able to order prescriptions electronically)

Information technology can be a potential assistant to physicians to improve their diagnostic skills. Briefly discuss three IT-related strategies to help improve diagnosis in medicine.

- They can use patient barcoding, they can use prescription tracking, use shareable charts software (recording and sharing assessments), algorithms (help physicians make the right choice)

Discuss the principle of conservative prescribing (pg.70)

- Think beyond drugs - Practice more strategic prescribing - Maintain heightened vigilance regarding adverse effects - Approach new drugs and new indications cautiously and skeptically - Work with patients for a more deliberate shared agenda - Consider longer-term, broader effects

Describe or explain the "Swiss cheese model" of organizational accidents. **describe layers in an example

- This model emphasizes that analyses of medical errors need to focus on their root causes and all the underlying conditions that made an error possible - Different levels of different errors and minimizing the holes in each level

Non-surgical, bedside procedures are also risky. Give some examples of these bedside procedures and provide a description of the strategies used to reduce their risk. (pg.92)

- Thoracentesis - Central line placement - Central venous catheter placement - Paracentesis - Lumbar puncture - Arthrocentesis - Preventing infections. Strategies to decrease risks of procedures fall into several categories: education and skill building, policies and practices, to decrease overall process risks such as wrong-patient and wrong-site procedures, adjunctive technologies, and organizational changes.

Describe the process of "usability testing". How is it employed in healthcare? Pg.125

- Usability testing is where experts observe frontline workers engaging in their task under realistic conditions either real patient care or stimulated environments that closely replicate reality. - It is used to address and correct errors in healthcare. Depending on a product and how it is used it might point to issues. It could be observing healthcare workers with simplistic thing or complicated things. **In the context of HFE, though, heuristics have a different connotation: "rules of thumb"

Checklists are used in many areas of healthcare. Discuss the ideal components of a checklist for diagnostics, and how the components improve diagnostic reasoning.

- Using medical history - Perform a focuses and purposeful medical exam - Take a diagnostic time out - pause and reflect - Generate hypothesis - Embark on a plan but acknowledge uncertainty and ensure a pathway for follow up.

. One type of high-risk handoff is discharge from a hospital. Describe at least four pieces of information that are imperative to share with the patient and his/her caregiver/advocate at this time, and discuss how this information should be presented. Ph.145

- Why they were hospitalization - What treatment they received - Test results should contact in case of an emergency - Medication usage - At home care - What you should and shouldn't do at home care - Precautions

List the eight goals to improve diagnosis & briefly discuss each one.

1) Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families 2) Enhance health care professional education and training in the diagnostic process 3) Ensure that health information technologies support patients and health care professionals in the diagnostic process 4) Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice 5) Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance 6) Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses 7) Design a payment and care delivery environment that supports the diagnostic process 8) Provide dedicated funding for research on the diagnostic process and diagnostic errors.

Discuss the similarities and differences among these domains (from Johnson text) and the core competencies suggested in the IOM report.

-Both have patient centered care - Practiced-based learning and practice - quality improvement can fall under personal and professional development

What are some of the reasons why diagnostic errors have received relatively little attention, despite being a major type of error?

-There is not a lot of data on them because it is hard to find the errors. (Harder to fix) - Different layers to it - Cultural attitudes - Clinicians get limited feedback on their diagnostic processes - There is a disagreement between the scenarios - Lack of recognition amount doctors - no pointed education on error recognition

The book discusses two primary views regarding diagnostic errors, cognitive and process-related. A cognitive technique called "iterative hypothesis testing" seems to be associated with good diagnosticians. Describe iterative hypothesis testing and how skilled physicians use it to make accurate diagnoses.

....

What is the "brain-to-brain" loop, and how does it relate to diagnostic decision-making?

Same physician, general step to step way to decision-making. You can make the right, correct decisions all day but it must be done in a timely manner for the patient. Diagnostic decision-making must be correct and timely.

Negligence

Some errors involve care that falls below a professional standard of care and are call negligence and may create legal liability or a duty to compensate the patient in some systems SYN. - carelessness

List some of the common methods/strategies used to enumerate medical errors. What are the advantages and disadvantages of each method?

· Trigger tools - emerged as a favored method to measure the incidence of adverse events in many healthcare settings. (in real time typically) - Advantage: The premise behind trigger tools is that some errors in care will engender a response that can be tracked. - best used as a screen, followed by more detailed chart review - Disadvantage: overall effectiveness remains uncertain - Their use in the outpatient world will need further study · Hospital standardized mortality ratios (HSMR) - first published in 2001 in the United Kingdom, a method pioneered by Professor Brian Jarman of Imperial College London, has generated significant enthusiasm. - Advantage: this measure became a major focus of quality and safety efforts in the United Kingdom, and the finding of high HSMR triggered several hospital investigations - Disadvantage: Was criticized heavily due to inadequate risk adjustment methods as well as the low number of deaths thought to be truly preventable. · Strategies: ask patients themselves to identify instances of harm or errors - Advantage: grows out of a broader movement to engage patients in their own safety and respect their roles as active participants in care - Disadvantage: the overall utility of this strategy, including whether placing patients in this position compromises their sense of trust in their caregivers, has not yet been fully defined. · Incident report systems - depend upon the individuals involved to relay those reports. Can be very useful but you must get them to report it.