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CLINICAL BIOCHEMISTRY Lecture Notes Simon Walker LN Geoffrey . of clinical cases has under the authorship of Professor Gordon Whitby, Dr been for Clinical PEM protein-energy malnutrition Chemistry PKU phenylketonuria IFG . own unique identiier (typically a bar code which because of electronic download of. Chemical Tests Performed Close to the Patient, in the Ward or Clinic Rev ed. of : Lecture notes on clinical chemistry / L.G. Whitby, A.F. Smith, G.J. Beckett. ISBN (ePub) — ISBN (Mobi) — ISBN — Clinical Chemistry Tests. 3. Clinical 20 Therapeutic drug monitoring and chemical toxicology, under the authorship of Professor Gordon Whitby, Dr .. Clinical Biochemistry Lecture Notes, Ninth Edition. S. Walker.
They created a novel fishbone root cause analysis procedure, which visually represents the multiple cause and effect relationships responsible for an error Trowbridge, Organizations and individuals can also take advantage of continuing education opportunities focused on using root cause analysis to study diagnostic errors in order to improve their ability to identify and understand diagnostic errors Reilly et al.
The cognitive autopsy is a variation of a root cause analysis that involves a clinician reflecting on the reasoning process that led to the error in order to identify causally relevant shortcomings in reasoning or decision making Croskerry, These can be useful, especially if they are framed from a patient safety perspective rather than focusing on attributing blame.
Other analytical methods used in human factors and ergonomics research could also be applied in health care organizational settings to further elucidate the work system components that contribute to diagnostic errors see Chapter 3 Bisantz and Roth, ; Carayon et al. As health care organizations develop a better understanding of diagnostic errors within their organizations, they can begin to implement and evaluate interventions to prevent or mitigate these errors as part of their patient safety, research, and quality improvement efforts.
To date, there have been relatively few studies that have evaluated the impact of interventions on improving diagnosis and reducing diagnostic errors and near misses; three recent systematic reviews summarized current interventions Graber et al. These reviews found that the measures used to evaluate the interventions were quite heterogeneous, and there were concerns about the generalizability of some of the findings to clinical practice.
Health care organizations can take into consideration some of the methodological challenges identified in these reviews in order to ensure that their evaluations generate much-needed evidence to identify successful interventions. The Medicare conditions of participation and accreditation organizations can be leveraged to ensure that health care organizations have appropriate programs in place to identify diagnostic errors and near Page Share Cite Suggested Citation:"6 Organizational Characteristics, the Physical Environment, and the Diagnostic Process: Improving Learning, Culture, and the Work System.
The Medicare conditions of participation are requirements that health care organizations must meet in order to receive payment CMS, a. State survey agencies and accreditation organizations such as The Joint Commission, the Healthcare Facilities Accreditation Program, the Accreditation Commission for Health Care, the College of American Pathologists, and Det NorskeVeritas-Germanischer Lloyd determine whether organizations are in compliance with the Medicare conditions of participation through surveys and site visits.
Some of these organizations accredit the broad range of health care organizations, while others confine their scope to a single type of health care organization. Other accreditation bodies, such as the National Committee for Quality Assurance NCQA , provide administrative and clinical accreditation and certification of health plans and provider organizations. Accreditation processes, federal oversight, and quality improvement efforts specific to diagnostic testing can also be used to ensure quality in the diagnostic process see Chapter 2.
By leveraging the Medicare conditions of participation requirements and accreditation processes, it may be possible to use the existing oversight programs that health care organizations have in place to monitor the diagnostic process and to ensure that the organizations are identifying diagnostic errors and near misses, learning from them, and making timely efforts to improve diagnosis. Thus, the committee recommends that accreditation organizations and the Medicare conditions of participation should require that health care organizations have programs in place to monitor the diagnostic process and identify, learn from, and reduce diagnostic errors and near misses in a timely fashion.
As more is learned about successful program approaches, accreditation organizations and the Medicare conditions of participation should incorporate these proven approaches into updates of these requirements. Postmortem Examinations The committee recognized that many approaches to identifying diagnostic errors are important, but the committee thought that the postmortem examination also referred to as an autopsy warranted additional committee focus because of its role in understanding the epidemiology of diagnostic error.
Postmortem examinations are typically performed to determine cause of death and can reveal discrepancies between premortem and postmortem clinical findings see Chapter 3. One of the contributors to the decline is that in The Joint Commission eliminated the requirement that hospitals conduct these examinations on a certain percentage of deaths in their facility—20 percent in community hospitals and 25 percent in teaching facilities—in order to receive accreditation Allen, ; CDC, Insurers do not directly pay for postmortem examinations, as they typically limit payment to procedures for living patients.
Medicare bundles payment for postmortem examinations into its payment for quality improvement activities, which may also disincentivize their performance Allen, Given the steep decline in postmortem examinations, there is interest in increasing their use. For example, Hill and Anderson recommended that half of all deaths in hospitals, nursing homes, and other accredited medical facilities receive a postmortem examination.
Lundberg recommended reinstating the mandate that a percentage of hospital deaths undergo postmortem examination, either to meet Medicare conditions of participation or accreditation standards. The committee concluded that a new approach to increasing the use of postmortem examinations is warranted.
The committee weighed the relative merits of increasing the number of postmortem examinations conducted throughout the United States versus a more targeted approach. In these circumstances, the committee concluded that health care organizations should continue to perform these postmortem examinations.
In addition, the committee concluded that it is appropriate to have a limited number of highly qualified health care systems participate in conducting routine postmortem exams that produce research-quality information about the incidence and nature of diagnostic errors. Thus, the committee recommends that the Department of Health and Human Services HHS should provide funding for a designated subset of health care systems to conduct routine postmortem examinations on a representative sample of patient deaths.
A competitive grant process could be used to identify these systems. This approach will likely provide better epidemiologic data and it represents an advance over current selection methods for performing postmortem examinations, because clinicians do not seem to be able to predict cases in which diagnostic errors will be found Shojania et al. The data collected from health care systems that are highly qualified to conduct routine postmortem examinations may not be representative of all systems of care.
However, the committee concluded that this is a more feasible approach, given the financial and workforce demands of conducting postmortem examinations. Findings from the health care systems that perform routine postmortem examinations can then be disseminated to the broader health care community. Participating health care systems could be required to produce annual reports on the epidemiology of diagnostic errors found by postmortem exams, the value of postmortem examinations as a tool for identifying and reducing such errors, and, if relevant, the role and value of postmortem examinations in quality improvement efforts.
These health care systems could also investigate how new, minimally invasive postmortem approaches compare with traditional full body postmortem examinations. Less invasive approaches include the use of medical imaging, laparoscopy, biopsy, histology, and cytology. For example, instead of conducting a full body postmortem exam, pathologists could biopsy tissue samples from an organ where disease is suspected and conduct molecular analysis van der Linden et al.
Some studies suggest that minimally invasive postmortem examinations including a combination of medical imaging with other minimally invasive postmortem investigations have been found to have accuracy similar to that of conventional postmortem examinations in fetuses, newborns, and infants Lavanya et al.
Further understanding the benefits and limitations of minimally invasive approaches may provide critical information moving forward. If successful approaches to minimally invasive postmortem examinations are found, they could play a role in reestablishing the practice of routine postmortem investigation in medicine Saldiva, Improving Feedback Feedback is a critical mechanism that health care organizations can use to support continuous learning in the diagnostic process.
The Best Care at Lower Cost report called for the creation of feedback loops that support continuous learning and system improvement IOM, As it relates to diagnosis, feedback entails informing an individual, team, or organization about its diagnostic performance, including its successes, near misses, and diagnostic errors Black, ; Croskerry, ; Gandhi, ; Gandhi et al.
The committee received substantial input indicating that there are limited opportunities for feedback on diagnostic performance Dhaliwal, ; Henriksen, ; Schiff, ; Singh, ; Trowbridge, There are often not systems in place to provide clinicians with input on whether they made an accurate, timely diagnosis or if their patients experienced a diagnostic error.
The failure to follow up with patients about their diagnosis and treatment—in both the near term and the long term—is a major gap in improving diagnosis. The committee concluded that improving diagnostic performance requires feedback at all levels of health care. Feedback can help clinicians assess how well they are performing in the diagnostic process, correct overconfidence, identify when remediation efforts are needed, and reduce the likelihood of repeated mistakes Berner and Graber, ; Croskerry and Norman, Feedback on diagnostic performance can also provide opportunities for health care organizational learning and improvements to the work system Plaza et al.
To improve the opportunities for feedback, the committee recommends that health care organizations should implement procedures and practices to provide systematic feedback on diagnostic performance to individual health care professionals, care teams, and clinical and organizational leaders. Box identifies some characteristics for effective feedback interventions Hysong et al. Feedback interventions in high-performing organizations have been found to share a number of characteristics, including being actionable, timely, individualized, and nonpunitive; a nonpunitive culture helps foster an environment in which Page Share Cite Suggested Citation:"6 Organizational Characteristics, the Physical Environment, and the Diagnostic Process: Improving Learning, Culture, and the Work System.
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