Root cause analysis of cases involving diagnosis.

IF 2.2 Q2 MEDICINE, GENERAL & INTERNAL
Diagnosis Pub Date : 2024-09-03 eCollection Date: 2024-11-01 DOI:10.1515/dx-2024-0102
Mark L Graber, Gerard M Castro, Missy Danforth, Jean-Luc Tilly, Pat Croskerry, Rob El-Kareh, Carole Hemmalgarn, Ruth Ryan, Michael P Tozier, Bob Trowbridge, Julie Wright, Laura Zwaan
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引用次数: 0

Abstract

Diagnostic errors comprise the leading threat to patient safety in healthcare today. Learning how to extract the lessons from cases where diagnosis succeeds or fails is a promising approach to improve diagnostic safety going forward. We present up-to-date and authoritative guidance on how the existing approaches to conducting root cause analyses (RCA's) can be modified to study cases involving diagnosis. There are several diffierences: In cases involving diagnosis, the investigation should begin immediately after the incident, and clinicians involved in the case should be members of the RCA team. The review must include consideration of how the clinical reasoning process went astray (or succeeded), and use a human-factors perspective to consider the system-related contextual factors in the diagnostic process. We present detailed instructions for conducting RCA's of cases involving diagnosis, with advice on how to identify root causes and contributing factors and select appropriate interventions.

对涉及诊断的案例进行根本原因分析。
诊断错误是当今医疗保健领域威胁患者安全的主要因素。学习如何从诊断成功或失败的案例中吸取经验教训,是提高诊断安全性的一个很有前途的方法。我们将提供最新的权威指导,说明如何修改现有的根本原因分析 (RCA) 方法,以研究涉及诊断的案例。其中有几处不同之处:在涉及诊断的案例中,调查应在事件发生后立即开始,参与案例的临床医生应成为 RCA 小组的成员。审查必须包括考虑临床推理过程是如何误入歧途(或成功)的,并从人为因素的角度考虑诊断过程中与系统相关的背景因素。我们提供了对涉及诊断的病例进行 RCA 的详细说明,并就如何确定根本原因和诱因以及选择适当的干预措施提出了建议。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Diagnosis
Diagnosis MEDICINE, GENERAL & INTERNAL-
CiteScore
7.20
自引率
5.70%
发文量
41
期刊介绍: Diagnosis 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.  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
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