Developing checklists to prevent diagnostic error in emergency room settings

Diagnosis

Volumn 1, Issue 3, 2014, Pages 223-231

  Graber, Mark L ^a   Sorensen, Asta V ^b   Biswas, Jon ^c   Modi, Varsha ^d   Wackett, Andrew ^e   Johnson, Scott ^e   Lenfestey, Nancy ^b   Meyer, Ashley N D ^d   Singh, Hardeep ^d  

^a STONY BROOK UNIVERSITY   (United States)

^b RTI INTERNATIONAL   (United States)

^c MICHAEL E DEBAKEY VETERANS AFFAIRS MEDICAL CENTER   (United States)

^d BAYLOR COLLEGE OF MEDICINE   (United States)

^e STONY BROOK UNIVERSITY MEDICAL CENTER   (United States)

Author keywords

Checklist; Clinical reasoning; Diagnosis; Diagnostic error; Emergency medicine

Indexed keywords

ABDOMINAL PAIN; ARTICLE; CHECKLIST; CONSULTATION; DIAGNOSTIC ERROR; DIFFERENTIAL DIAGNOSIS; EMERGENCY WARD; HEALTH CARE UTILIZATION; HUMAN; LABORATORY TEST; MEDICAL RECORD REVIEW; MULTICENTER STUDY; PHYSICIAN; PILOT STUDY; PRIORITY JOURNAL; SAMPLE SIZE; STRUCTURED INTERVIEW; THORAX PAIN; UNIVERSITY HOSPITAL;

EID: 84962710821     PISSN: 21948011     EISSN: 2194802X     Source Type: Journal    
DOI: 10.1515/dx-2014-0019     Document Type: Article

References (39)

1. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121:S2-23.
2. Graber M. The incidence of diagnostic error. BMJ Qual Saf 2013;22, Part 2: ii21-ii7.
3. Singh H, Traber D, Meyer A, Forjuoh S, Reis M, Thomas E. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med 2013;173:418-25.
4. Newman-Toker D, Makary M. Measuring diagnostic errors in primary care - the first step on a path forward. JAMA Intern Med 2013;173:425-6.
5. Leape L, Berwick D, Bates D. Counting deaths from medical errors. J Am Med Assoc 2002;288:2405.
6. Kachalia A, Gandhi T, Puopolo A, Yoon C, Thomas EJ, Griffey R, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2006;19:196-205.
7. Graber M, Kissam S, Payne V, Meyer AN, Sorenson A, Lenfestey N, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf 2012;21:535-57.
8. Singh H, Graber M, Kissam S, Sorensen AV, Lenfestey NF, Tant EM, et al. System-related interventions to reduce diagnostic errors: a narrative review. BMJ Qual Saf 2012;21:160-70.
9. McDonald K, Matesic B, Contopoulos-Iannidis D, Lonhart J, Schmidt E, Pineda N, et al. Patient safety strategies targeted at diagnostic errors - a systematic review. Ann Int Med 2013;158:381-9.
10. El-Kareh R, Hasan O, Schiff G. Use of health information technology to reduce diagnostic error. BMJ Qual Saf 2013;22ii: 40-4.
11. Croskerry P, Singhal G, Mamede S. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf 2013;22ii: 65-72.
12. Thomas N, Ramnarayan P, Bell M, Maheshwari P, Wilson S, Nazarian EB, et al. An international assessment of a web-based diagnostic tool in critically ill children. Technol Health Care 2008;16:103-10.
13. Ramnarayan P, Cronje N, Brown R, Negus R, Coode B, Moss P, et al. Validation of a diagnostic reminder system in emergency medicine: a multi-centre study. Emerg Med J 2007;24:619-24.
14. Cervellin G, Borghi L, Lippi G. Do clinicians decide relying primarily on Bayesian principles or Gestalt perception? Some pearls and pitfalls of Gestalt perception in medicine. Intern Emerg Med 2014. DOI 10.1007/s11739-014-1049-8.
15. Gawande A. The checklist manifesto: how to get things right, 1st ed. New York: Metropolitan Books, 2010.
16. Ko H, Turner T, Finnigan M. Systematic review of safety checklists for use by medical care teams in acute care hospitals - limited evidence of effectiveness. BMC Health Serv Res 2011;11:211.
17. The Matching Michigan Collaboration and Writing Team. Matching Michigan: a 2-year stepped intervention programme to minimse central venous catheter-blood stream infections in intensive care units in England. BMJ Qual Saf 2013;22:110-23.
18. Pronovost P, Needham D, Berenholz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32.
19. Treadwell J, Lucas S, Tsou A. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf 2014;23:299-318.
20. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2010;360:491-9.
21. Ely JW, Osheroff JA. Checklists to prevent diagnostic errors. Abstract, Presented at: Diagnostic Error in Medicine Annual Conference, Phoenix-AZ, 2008.
22. Ely JW, Graber M, Croskerry P. Checklists to reduce diagnostic errors. Acad Med 2011;86:307-13.
23. Hales B, Terblanche M, Fowler R, Sibbald W. Development of medical checklists for improved quality of patient care. Int J Qual Health Care 2008;20:22-30.
24. Thomassen O, Espeland A, Softeland E, Lossius H, Heltne J, Brattebo G. Implementation of checklists in health care; learning from high-reliability organisations. Scand J Trauma Resusc Emerg Med 2011;19:53.
25. Degani A, Weiner E. Cockpit checklists: concepts, design, and use. Human Factors 1993;35:28-43.
26. Graber M. Educational interventions to reduce diagnostic error - can you teach this stuff? Adv Health Sci Educ Theory Pract 2009;14:63-9.
27. Yin RK. Case study research: design and methods. Thousand Oaks, CA: Sage Publications, Inc., 1994.
28. Miles M, Huberman A. Qualitative analysis: an expanded sourcebook, 2nd ed. Thousand Oaks, CA: Sage Publications, 1994.
29. Graber ML, Franklin N, Gordon RR. Diagnostic error in internal medicine. Arch Int Med 2005;165:1493-9.
30. Shimizu T, Kentaro M, Tokuda Y. Effects of the use of differential diagnosis checklist and general de-biasing checklist on diagnostic performance in comparison to intuitive diagnosis. Med Teacher 2013;35:e1218-e29.
31. White R, Trbovich PL, Easty AC, Savage P, Trip K, Hyland S. Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model. Qual Saf Health Care 2010;19:562-7.
32. Sibbald M, De Bruin A, Van Merrienboer J. Checklists improve experts' diagnostic decisions. Med Educ 2013;47:301-8.
33. Sibbald M, De Bruin ABH, Cavalcanti RB, Van Merrienboer JJG. Do you have to re-examine your diagnosis? Checklists and cardiac exam. BMJ Qual Saf 2013;22:333-338.
34. Meyer AN, Payne VL, Meeks DW, Rao R, Singh H. Physicians' diagnostic accuracy, confidence, and resource requests. JAMA Internal Med 2013;173:1952-8.
35. Podbregar M, Voga G, Krivec B, Skale R, Pareznik R, Gabrscek L. Should we confirm our clinical diagnostic certainty by autopsies? Intensive Care Med 2001;27:1750-5.
36. Friedman CP, Gatti GG, Franz TM, Murphy GC, Wolf FM, Heckerling PS, et al. Do physicians know when their diagnoses are correct? Implications for decision support and error reduction. J Gen Intern Med 2005;20:334-9.
37. Chopra V, Shojania K. Recipe for checklists and bundles - one part active ingredient and one part measurement. Qual Saf Health Care 2013;22:93-6.
38. Dixon-Woods M, Bosk C, Aveling E, Goeschel C, Pronovost P. Explaining Michigan: developing an ex-post theory of a quality improvement program. Milbank Q 2011;89:167-205.
39. Bosk CL, Dixon-Woods MS, Goeschel CA, Pronovost P. Reality check for checklists. Lancet 2009;374:444-5.