Re-engineering Patient and Family Communication to Improve Diagnostic Safety Resilience

摘要 随着时间的推移，诊断过程在多个设置中展开。每个设置中的错误的风险因素可能 有所不同，但对于患者来说，一旦发生严重的诊断错误，发生的具体临床区域是 无关紧要。门诊部和住院部的诊断性伤害比率相似。和内的交互作用 临床团队和环境之间的冲突可能会创造韧性或增加失败的风险。恢复力 工程学，或称安全II，是基于这样一个概念：安全是适应变化的结果 系统运行的条件。强大的通信支持共享的心理模型，这可能会创建 诊断复原力。目前，临床医生-患者/家人在诊断过程中的沟通是 随心所欲。例如，儿科医生总是不告诉父母“危险信号”，这是一种 需要立即注意的严重并发症。在家里患有慢性病的儿童中，我们发现 这14%的人由于父母对说明的误解而导致严重的诊断延误。儿科 诊断安全性研究不足，门诊儿科诊断错误的总体比率和类型是 未知。为了支持与住院儿童的家庭进行强有力的沟通，我们开发了一个结构化的 沟通干预(PFC I-PASS)，将医疗差错减少38%。I-PASS已经进行了试点测试 在出院期间使用，取得了类似的成功。二次分析表明I-PASS可能是 有效减少诊断错误。PFC I-PASS尚未在门诊环境中使用及其影响 关于诊断的安全性还没有经过测试。在患有多种慢性病的儿童中，我们的目标是：1. 描述诊断过程，重点关注成功、错误以及患者/家人和临床医生 沟通；2.调整PFC I-PASS以创建门诊PFC I-PASS，这是一种结构化的沟通 对门诊患者/家属和临床医生的干预；3.评估PFC I- 通过(门诊和出院)以改善患者/家人和临床医生的沟通和体验，以及 以减少错误和危害。拟议的卓越诊断中心由两个核心组成：a 方法核心和教育和传播核心。核心包括诊断安全方面的专业知识， 安全一和安全二、沟通、医学教育和健康差距。这些核心将与Patient和 家长、临床医生和卫生系统领导咨询小组。辛辛那提波士顿儿童医院 儿童医院医疗中心和费城儿童医院，为了解决AIMS，我们将雇用 观察、访谈、模拟、调查、图表回顾，使用S1和S2方法。我们将评估 使用中断时间序列分析改进的PFC-IPASS对诊断错误的影响。方法将是 立即提供给其他卓越诊断中心，并通过几个网络提供给200多家 卫生系统。结合S1和S2方法来确定诊断过程和测试干预的特征 有可能改变患者安全科学。

ABSTRACT The diagnostic process unfolds across multiple settings over time. Risk factors for error in each setting may vary, but for the patient, once a serious diagnostic error occurs, the specific clinical area where it happened is unimportant. Outpatient and inpatient settings have similar rates of diagnostic harm. Interactions within and between clinical teams and settings may either create resilience or increase risks for failure. Resilience engineering, or Safety II, is based on the concept that safety is a consequence of adaptations to the changing conditions of a system’s function. Robust communication supports a shared mental model that may create diagnostic resilience. Currently, clinician-patient/family communication along the diagnostic journey is haphazard. For example, pediatricians consistently fail to tell parents about “red flags” which are signs of a serious complication requiring immediate attention. Among children with chronic conditions at home, we found that 14% had serious diagnostic delays caused by parental misunderstanding of instructions. Pediatric diagnostic safety is understudied, and overall rates and types of outpatient pediatric diagnostic errors is unknown. To support robust communication with families of hospitalized children, we developed a structured communication intervention (PFC I-PASS) which reduces medical errors by 38%. I-PASS has been pilot tested for use during hospital discharge with similar success. Secondary analyses suggests that I-PASS may be effective at reducing diagnostic errors. PFC I-PASS has not been used in the outpatient setting and its impact on diagnostic safety has not been tested. Among children with multiple chronic conditions, we aim to: 1. Characterize the diagnostic journey, focusing on successes, errors, and patient/family and clinician communication; 2. Adapt PFC I-PASS to create Outpatient PFC I-PASS, a structured communication intervention for patients/families and clinicians in the outpatient setting; 3. Evaluate the effectiveness of PFC I- PASS (outpatient and discharge) to improve patients/family and clinician communication and experience, and to reduce errors and harm. The proposed Diagnostic Center of Excellence is comprised of two cores: a Methods Core and an Education and Dissemination Core. Cores include expertise in the diagnostic safety, Safety I and II, communication, medical education, and health disparities. The cores will work with Patient and Parent, Clinician, and Health System Leader Advisory Panels. At Boston Children’s Hospital, Cincinnati Children’s Hospital Medical Center and Children’s Hospital of Philadelphia, to address aims, we will employ observations, interviews, simulation, surveys, chart review, using S1 and S2 approaches. We will evaluate the impact of adapted PFC-IPASS on diagnostic errors using interrupted time series analysis. Methods will be immediately available to other Centers of Diagnostic Excellence and, through several networks, to over 200 health systems. Combining S1 and S2 approaches to characterize the diagnostic journey and test interventions has the potential to transform patient safety science.