Developing checklists to prevent diagnostic error in Emergency Room settings.
Developing checklists to prevent diagnostic error in Emergency Room settings.
复制标题
DOI：
10.1515/dx-2014-0019
复制
发表时间：
2014-09
期刊：
影响因子：
--
通讯作者：
Singh H
中科院分区：
文献类型：
--
作者：
Graber ML;Sorensen AV;Biswas J;Modi V;Wackett A;Johnson S;Lenfestey N;Meyer AN;Singh H
事实证明，清单可以提高复杂且容易出错的流程的性能。制定一份检查表，有可能降低因未确诊病情而前往急诊室 (ER) 的患者出现诊断错误的可能性。参与者包括在两个大型学术中心工作的 15 名急诊医生。使用快速循环设计和评估流程来针对容易出现诊断错误的高风险情况制定通用检查表。医生使用一般检查表和一组针对特定症状的检查表为期两个月。我们进行了混合方法评估，包括有关用户看法的访谈以及清单使用前后资源利用率的定量评估。通过获取用户和主题专家的反馈，迭代开发了一份通用清单，并与 ER 中的一组具体清单一起进行了试用。一般检查表和特定症状检查表都被认为是有帮助的，但稍微倾向于使用特定症状检查表。检查表的使用通常会促使考虑额外的诊断可能性，改变大约 10% 病例的工作诊断，并且据说有助于避免诊断错误。检查表的使用是由多种不同因素推动的，而不仅仅是诊断的不确定性。尽管鼓励医生这样做，但没有一位医生与患者合作使用检查表。检查表的使用并未导致测试顺序或咨询发生较大变化。在急诊室环境中，诊断检查表有助于考虑其他诊断可能性，从而有可能防止诊断错误。使用不一致以及私下而不是与患者一起使用检查表是可能妨碍获得最大益处的因素。需要进一步的研究来优化急诊室使用的检查表，确定如何增加使用量，评估检查表的使用对错误率和患者结果的影响，确定检查表的使用如何影响测试顺序和咨询，并将检查表与其他方法进行一般比较以减少诊断错误。
Checklists have been shown to improve performance of complex, error-prone processes. To develop a checklist with potential to reduce the likelihood of diagnostic error for patients presenting to the Emergency Room (ER) with undiagnosed conditions. Participants included 15 staff ER physicians working in two large academic centers. A rapid cycle design and evaluation process was used to develop a general checklist for high-risk situations vulnerable to diagnostic error. Physicians used the general checklists and a set of symptom-specific checklists for a period of 2 months. We conducted a mixed methods evaluation that included interviews regarding user perceptions and quantitative assessment of resource utilization before and after checklist use. A general checklist was developed iteratively by obtaining feedback from users and subject matter experts, and was trialed along with a set of specific checklists in the ER. Both the general and the symptom-specific checklists were judged to be helpful, with a slight preference for using symptom-specific lists. Checklist use commonly prompted consideration of additional diagnostic possibilities, changed the working diagnosis in approximately 10% of cases, and anecdotally was thought to be helpful in avoiding diagnostic errors. Checklist use was prompted by a variety of different factors, not just diagnostic uncertainty. None of the physicians used the checklists in collaboration with the patient, despite being encouraged to do so. Checklist use did not prompt large changes in test ordering or consultation. In the ER setting, checklists for diagnosis are helpful in considering additional diagnostic possibilities, thus having potential to prevent diagnostic errors. Inconsistent usage and using the checklists privately, instead of with the patient, are factors that may detract from obtaining maximum benefit. Further research is needed to optimize checklists for use in the ER, determine how to increase usage, to evaluate the impact of checklist utilization on error rates and patient outcomes, to determine how checklist usage affects test ordering and consultation, and to compare checklists generally with other approaches to reduce diagnostic error.