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Showing results for tags 'Diagnosis'.
Found 469 results
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Content ArticleThis is a story of a patient in whom the emergency department missed the same diagnosis twice, four years apart. The first occasion (prior to his diagnosis of ankylosing spondylitis) was understandable. The second was not. As a result of this case, the hospital have changed their x-ray policy for non-traumatic back pain. They also want to share key learning points (the majority of which were due to lack of awareness about a relatively rare condition and its complications) as widely as possible, to help others avoid the same errors. This reflective learning features guest educator, Mr Gareth Dwyer (the patient).
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Content ArticleNewborn babies may need extra care in a neonatal intensive care unit or special care baby unit if they were born prematurely or if they need care for a particular health condition. Babies and infants that need long-term care can be transferred to a local unit or discharged to receive care at home. A baby with complex health needs may move between distinct areas of care or 'pathways'. This Care Quality Commission (CQC) review looked at how risks for newborn babies are identified and managed and at the care for infants in the community who need respiratory support. This review draws on one particular case that had a tragic outcome for a baby and her parents. Elizabeth Dixon was born prematurely but suffered brain damage as a result of missed high blood pressure. She died shortly before her first birthday in 2001, when there was a failure to correctly maintain her tracheostomy tube. While this review was not an investigation of the specific circumstances of Elizabeth's case, it drew on this to examine current practice, systems and guidance.
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Content ArticleRisk scores are widely used in healthcare, but their development and implementation do not usually involve input from practitioners and service users and carers (SU/C). This study from Dyson et al., published in BMJ Open contributes to the development of The Computer-Aided Risk Score (CARS) by eliciting views of staff and who provided important, often complex, insights to support the development and implementation of CARS to ensure successful implementation in routine clinical practice.
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Content ArticleIn 2019, the US-based National Quality Forum (NQF), is convening a new multi-stakeholder expert committee to revisit and build on the work of the Diagnostic Quality and Safety Committee. This report updates a scan done when the National Quality Framework (NQF) diagnostic measures framework first came out in 2017. The assessment of the current state of diagnostic errors measurement, themes that have emerged since the earlier document and new measures that have been published may be of interest to researchers in the UK doing work in this important segment of patient safety work.
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Content Article
Review of national cancer screening programmes in England
Patient Safety Learning posted an article in Cancers
Leading expert Professor Sir Mike Richards was jointly commissioned by NHS chief executive Simon Stevens and Health and Social Care Secretary Matt Hancock to make recommendations on overhauling national screening programmes, as part of a new NHS drive for earlier diagnosis and improved cancer survival. -
Content ArticleGiven an unacceptably high incidence of diagnostic errors, the authors sought to identify the key competencies that should be considered for inclusion in health professions education programmes to improve the quality and safety of diagnosis in clinical practice. Olsen et al. believe that one of the most promising and sustainable ways to improve diagnosis is to improve education and training in the health professions. The first step in this process is to define the outcomes that trainees in each profession must achieve in order to be effective members of a diagnostic team in the modern healthcare setting. This paper, published in Diagnosis journal, defines these competencies.
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Content ArticleStarfish tells Tom and Nic Ray's truly inspirational story of their life before, during and after sepsis which claimed Tom's lower arms, legs and a portion of his face. Heart-breakingly honest and affecting, their story charts the devastating effects of Tom's illness, Nic's heroic struggle to cope and, ultimately, the love and hope that has held their family together in the ensuing years.
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Content ArticleThe Care Quality Commission (CGC) is the independent regulator of health and adult social care in England. They make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve. Independent acute hospitals play an important role in delivering healthcare services in England, providing a range of services, including surgery, diagnostics and medical care. As the independent regulator, the CQC, hold all providers of healthcare to the same standards, regardless of how they are funded.
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Content Article
Letter from America: Lift off!
lzipperer posted an article in Letter from America
I’d like to introduce my ‘Letter from America’, a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery. -
Content ArticleThe purpose of this study was to describe patient engagement as a safety strategy from the perspective of hospitalised surgical patients with cancer.
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Content ArticleThe lack of follow-up or communication of unexpected significant findings can have a serious or life-threatening impact on patients. This was seen in the reference case that informed this Healthcare Safety Investigation Branch (HSIB) investigation. In this event, a 76-year old woman had a chest X-ray showing a possible lung cancer which was not followed up and resulted in a delayed diagnosis. The patient died just over two months after her diagnosis.
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Content ArticleSince the Government initially consulted on the package of Death Certification Reforms, new information about how Medical Examiner (ME) system could be introduced has been generated by the Department of Health and Social Care (DHSC), ME pilot sites, early adopters of the ME system, as well as from the Learning from Deaths initiative. This case study outlines the approach of South Tees Hospitals NHS Foundation Trust as one of the early adopter sites.
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Content Article
The incidence of diagnostic error in medicine (2013)
Patient Safety Learning posted an article in Diagnostic error
A wide variety of research studies suggest that breakdowns in the diagnostic process result in a staggering toll of harm and patient deaths. These include autopsy studies, case reviews, surveys of patient and physicians, voluntary reporting systems, using standardised patients, second reviews, diagnostic testing audits and closed claims reviews. Although these different approaches provide important information and unique insights regarding diagnostic errors, each has limitations and none is well suited to establishing the incidence of diagnostic error in actual practice, or the aggregate rate of error and harm. In this BMJ Quality & Safety article, Mark Graber argues that being able to measure the incidence of diagnostic error is essential to enable research studies on diagnostic error, and to initiate quality improvement projects aimed at reducing the risk of error and harm. Three approaches appear most promising in this regard: (1) using ‘trigger tools’ to identify from electronic health records cases at high risk for diagnostic error; (2) using standardised patients (secret shoppers) to study the rate of error in practice; (3) encouraging both patients and physicians to voluntarily report errors they encounter, and facilitating this process. -
Content ArticleThe great majority of medical diagnoses are made using automatic, efficient cognitive processes, and these diagnoses are correct most of the time. This analytic review from Berner and Graber in The American Journal of Medicine concerns the exceptions: the times when these cognitive processes fail and the final diagnosis is missed or wrong. The authors argue that physicians in general underappreciate the likelihood that their diagnoses are wrong and that this tendency to overconfidence is related to both intrinsic and systemically reinforced factors. They present a comprehensive review of the available literature and current thinking related to these issues. The review covers the incidence and impact of diagnostic error, data on physician overconfidence as a contributing cause of errors, strategies to improve the accuracy of diagnostic decision making, and recommendations for future research.
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Content ArticleErrors in clinical reasoning occur in most cases in which the diagnosis is missed, delayed or wrong. The goal of this review from Graber et al., published in BMJ Quality & Safety was to identify interventions that might reduce the likelihood of these cognitive errors. The authors identified a wide range of possible approaches to reduce cognitive errors in diagnosis. Not all the suggestions have been tested, and of those that have, the evaluations typically involved trainees in artificial settings, making it difficult to extrapolate the results to actual practice. Future progress in this area will require methodological refinements in outcome evaluation and rigorously evaluating interventions already suggested, many of which are well conceptualised and widely endorsed.
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Content ArticleDiagnosis is one of the most important tasks performed by primary care providers. Diagnostic errors can lead to patient harm from wrong or delayed testing or treatment. They have emerged as a global priority in patient safety. This report raises awareness among the World Health Organization (WHO) Member States about strategies that could be implemented to reduce diagnostic errors in primary care. After outlining the approach taken to compile information, it describes the importance of examining diagnostic errors, the most common types of diagnostic errors in primary care, and potential solutions.
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Content ArticleMedical misdiagnosis, in the form of inaccurate, late, and delayed diagnoses, is an ongoing problem in the United States. Not only do these diagnostic errors present an ongoing risk to the health and safety of patients, but they also cost the economy billions of dollars. This paper from Pinnacle Care summarises the key research findings on the frequency, human cost, and financial impact of these diagnostic errors, while providing new data on the value of second opinions. An extensive Institute of Medicine (IOM) report underscores the importance of this with its conclusion that most Americans will receive an inaccurate or late diagnosis at least once in their lives, often with life-threatening consequences.
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Content ArticleGetting the right diagnosis is a key aspect of health care — it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors—inaccurate or delayed diagnoses—persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errors—has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.
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Content ArticlePoster summarising the barriers in sharing learning across organisations in healthcare.
