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

摘要 诊断过程随着时间的推移在多个设置中展开。每种情况下的错误风险因素可能 不同，但对病人来说，一旦发生严重的诊断错误，发生错误的具体临床领域是 不重要.门诊和住院患者的诊断伤害率相似。内部互动， 临床团队和环境之间的差异可能会产生弹性或增加失败的风险。复原力 工程，或安全II，是基于这样的概念，即安全是适应变化的结果 一个系统的功能。强大的沟通支持共享的心理模型， 诊断复原力目前，临床医生-患者/家庭的沟通沿着诊断之旅是 偶然的例如，儿科医生总是不告诉父母“红旗”，这是一个迹象， 严重并发症，需要立即关注。在家中患有慢性病的儿童中，我们发现 14%的人因父母误解指示而导致严重的诊断延迟。儿科 诊断安全性研究不足，门诊儿科诊断错误的总体发生率和类型 未知为了支持与住院儿童家属的有力沟通，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已经过试点测试 在出院期间使用，取得了类似的成功。次要分析表明，I-PASS可能是 有效减少诊断错误。PFC I-PASS尚未用于门诊及其影响 诊断安全性尚未得到验证。在患有多种慢性疾病的儿童中，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/家属和临床医生 通信; 2.调整PFC I-PASS以创建门诊患者PFC I-PASS，一种结构化的沟通 对门诊患者/家属和临床医生的干预; 3.评估全氟化学品一的有效性- PASS（门诊和出院），以改善患者/家属和临床医生的沟通和体验，以及 减少错误和伤害。拟议的卓越诊断中心由两个核心组成： 方法核心以及教育和传播核心。核心包括诊断安全方面的专业知识， 安全I和II，通信，医学教育和健康差异。核心将与患者和 家长，临床医生和卫生系统领导者顾问小组。在辛辛那提的波士顿儿童医院 儿童医院医疗中心和费城儿童医院，为了实现目标，我们将雇用 观察，访谈，模拟，调查，图表审查，使用S1和S2方法。我们将评估 使用中断时间序列分析的适应PFC-IPASS对诊断错误的影响。方法将 立即提供给其他诊断卓越中心，并通过几个网络，超过200 卫生系统。结合S1和S2方法来描述诊断过程和测试干预措施 有可能改变病人安全科学。

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.