Increasing Physician Reporting of Diagnostic Learning Opportunities.

Autor:	Marshall TL; Divisions of Hospital Medicine and trisha.marshall@cchmc.org.; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and., Ipsaro AJ; Divisions of Hospital Medicine and., Le M; Pediatric Residency Training Program and., Sump C; Pediatric Residency Training Program and., Darrell H; Divisions of Hospital Medicine and., Mapes KG; Departments of Patient Services and., Bick J; Information Services and., Ferris SA; Divisions of Hospital Medicine and., Bolser BS; Divisions of Hospital Medicine and., Simmons JM; Divisions of Hospital Medicine and.; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and., Hagedorn PA; Divisions of Hospital Medicine and.; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.; Information Services and.; Biomedical Informatics and., Brady PW; Divisions of Hospital Medicine and.; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and.
Jazyk:	angličtina
Zdroj:	Pediatrics [Pediatrics] 2021 Jan; Vol. 147 (1). Date of Electronic Publication: 2020 Dec 02.
DOI:	10.1542/peds.2019-2400
Abstrakt:	Background: An estimated 10% of Americans experience a diagnostic error annually, yet little is known about pediatric diagnostic errors. Physician reporting is a promising method for identifying diagnostic errors. However, our pediatric hospital medicine (PHM) division had only 1 diagnostic-related safety report in the preceding 4 years. We aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months. Methods: Our improvement team used the Model for Improvement, targeting the PHM service. To promote a safe reporting culture, we used the term diagnostic learning opportunity (DLO) rather than diagnostic error, defined as a "potential opportunity to make a better or more timely diagnosis." We developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. The outcome measure, the number of DLO reports per 100 patient admissions, was tracked on an annotated control chart to assess the effect of our interventions over time. We evaluated DLOs using a formal 2-reviewer process. Results: Over the course of 13 weeks, there was an increase in the number of reports filed from 0 to 1.6 per 100 patient admissions, which met special cause variation, and was subsequently sustained. Most events (66%) were true diagnostic errors and were found to be multifactorial after formal review. Conclusions: We used quality improvement methodology, focusing on psychological safety, to increase physician reporting of DLOs. This growing data set has generated nuanced learnings that will guide future improvement work. Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. (Copyright © 2021 by the American Academy of Pediatrics.)
Databáze:	MEDLINE
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