Band 1, Heft 4

Timely and accurate communication is essential to safe and effective health care. Despite increased awareness over the past decade of the frequency of medical errors and greater efforts directed towards improving patient safety, patient harm due to communication breakdowns remains a significant problem. Communication problems related to diagnostic testing may account for nearly half of all errors made by typical primary care physicians in their medical practices. This article provides an overview of communication breakdowns in the context of radiology related diagnostic errors. In radiology, communication breakdowns between radiologists, referring clinicians, and patients can lead to failure of critical information to be relayed, resulting in delayed or missed diagnosis. New technologies, such electronic health records (EHRs), contribute to the increasing complexity of communication in health care, but if used correctly, they can provide several benefits to safe and effective communication. To address the complexity of communication breakdowns, a multifaceted sociotechnical approach is needed to address both technical and non-technical aspects of health care delivery. The article also provides some future directions in reducing communication breakdowns related to diagnostic testing, including proactive risk assessment of communication practices using recently released SAFER self-assessment guides.

Communication problems in diagnostic testing have increased in both number and importance in recent years. The medical and legal impact of failure of communication is dramatic. Over the past decades, the courts have expanded and strengthened the duty imposed on radiologists to timely communicate radiologic abnormalities to referring physicians and perhaps the patients themselves in certain situations. The need to communicate these findings goes beyond strict legal requirements: there is a moral imperative as well. The Code of Medical Ethics of the American Medical Association points out that “Ethical values and legal principles are usually closely related, but ethical obligations typically exceed legal duties.” Thus, from the perspective of the law, radiologists are required to communicate important unexpected findings to referring physicians in a timely fashion, or alternatively to the patients themselves. From a moral perspective, radiologists should want to effect such communications. Practice standards, moral values, and ethical statements from professional medical societies call for full disclosure of medical errors to patients affected by them. Surveys of radiologists and non-radiologic physicians reveal that only few would divulge all aspects of the error to the patient. In order to encourage physicians to disclose errors to patients and assist in protecting them in some manner if malpractice litigation follows, more than 35 states have passed laws that do not allow a physician’s admission of an error and apologetic statements to be revealed in the courtroom. Whether such disclosure increases or decreases the likelihood of a medical malpractice lawsuit is unclear, but ethical and moral considerations enjoin physicians to disclose errors and offer apologies.

Diagnostic pathways are an essential subset of clinical pathways and a logical consequence of DRG-based reimbursement. They combine the principle of stepwise reflex and reflective testing with a management concept that helps to fulfill medical needs with organizational and economic efficacy. The two most common formats describing diagnostic pathways are graphical decision trees on paper and “if…then…else” rules on computers. From a laboratory point of view, diagnostic pathways represent “smart” test profiles, which – in contrast to conventional (inflexible) profiles – are not necessarily worked off completely, but just to a point, where a diagnostic decision can be made. This improves the cost-effectiveness of laboratory testing, while making sure that no essential tests are missed. The paper describes benefits and limitations of diagnostic pathways from a medical, organizational, and economic point of view. Their major advantage is also their major drawback, since they make the diagnostic process on the one hand extremely straight-forward and transparent, while on the other hand oversimplifying the underlying medical decision principles. This may provoke the abuse of their primarily medical intentions for mere economic purposes.

Potassium and magnesium are important circulating cations and are predominantly intracellular elements. Only a small fraction of these elements is present in extracellular fluids including blood (∼1%). Measurement of the concentration of such small fractions in blood is commonly used to assess and reflect their body content levels. However, some of these measurements can be flawed and a failure to recognise the limitations of these tests may result in misdiagnosis and/or unnecessary follow-up investigations and/or expensive hospital admissions. The focus of this note is three-fold (a) to highlight and discuss separately the less appreciated pitfalls of potassium and magnesium measurements per se, (b) suggestions to identify and rectify these snags and to improve their clinical interpretation, and finally (c) to discuss briefly the clinical inter-relationship between these two predominantly most abundant intracellular cations without dwelling on details which are outside the scope of this note.

On September 30th, 2014, the Centers for Disease Control and Prevention (CDC) confirmed the first travel-associated case of US Ebola in Dallas, TX. This case exposed two of the greatest concerns in patient safety in the US outpatient health care system: misdiagnosis and ineffective use of electronic health records (EHRs). The case received widespread media attention highlighting failures in disaster management, infectious disease control, national security, and emergency department (ED) care. In addition, an error in making a correct and timely Ebola diagnosis on initial ED presentation brought diagnostic decision-making vulnerabilities in the EHR era into the public eye. In this paper, we use this defining “teachable moment” to highlight the public health challenge of diagnostic errors and discuss the effective use of EHRs in the diagnostic process. We analyze the case to discuss several missed opportunities and outline key challenges and opportunities facing diagnostic decision-making in EHR-enabled health care. It is important to recognize the reality that EHRs suffer from major usability and inter-operability issues, but also to acknowledge that they are only tools and not a replacement for basic history-taking, examination skills, and critical thinking. While physicians and health care organizations ultimately need to own the responsibility for addressing diagnostic errors, several national-level initiatives can help, including working with software developers to improve EHR usability. Multifaceted approaches that account for both technical and non-technical factors will be needed. Ebola US Patient Zero reminds us that in certain cases, a single misdiagnosis can have widespread and costly implications for public health.

Anticipating that the problem of diagnostic errors will not easily be solved through education, debiasing techniques or incentives-based systems, experts have proposed the systematic use of decision support tools (or decision aids) in medical practice. These tools are active knowledge resources that use patient data to generate case-specific advice to support clinical decision making. We argue that designing these decision support tools incorporates both discrete, analytical information as well as intuitive elements that would optimize their impact on clinical everyday activities. The use of fuzzy cognitive maps should allow developers to achieve this aim, by incorporating published evidence, intuition and qualitative assessment in a low-cost software program that could be implemented in various clinical settings.

Circadian rhythms are synchronized by the light/dark (L/D) cycle over the 24-h day. A suprachiasmatic nucleus in the hypothalamus governs time keeping based on melanopsin messages from the retina in the eyes and transduces regulatory signals to tissues through an array of hormonal, metabolic and neural outputs. Currently, vague impressions on circadian regulation in health and disease are replaced by scientific facts: in addition to L/D cyling, oscillation is maintained by genetic ( Clock , Bmal1 , Csnk1 , CHRONO , Cry , Per ) programs, autonomous feedback loops, including melatonin activities, aerobic glycolysis intensity and lipid signalling, among others. Such a multifaceted influential system on circadian rhythm is bound to be fragile and genomic clock acitvities can become disrupted by epigenetic modifications or such environmental factors as mistimed sleep and feeding schedules albeit leaving the centrally driven melatonin-dependent pacemakter more or less unaffected.

Nanotechnology has provided a plethora of valuable tools that can be applied for the detection of biomolecules and analytes relevant for diagnosis purposes – nanodiagnostics. This surging new field of molecular diagnostics has been revolutionizing laboratory procedures and providing new ways to assess disease biomarkers with increased sensitivity. While most of the reported nanodiagnostics systems are proof-of-concepts that demonstrate their efficacy in the lab, several nanodiagnostics platforms have already matured to a level that open the way for effective translation to the clinics. Nanodiagnostics platforms (e.g., gold nanoparticles containing systems) have been remarkably useful for the development of molecular diagnosis strategies for DNA/RNA detection and characterization, including systems suitable for point-of-care. How near are nanodiagnostics to go from the bench to the bedside?