Band 5, Heft 1

Diagnostic safety could theoretically be improved by high-level interventions, such as improving clinical reasoning or eliminating system-related defects in care, or by focusing more specifically on a single problem or disease. In this review, we consider how the timely diagnosis of sepsis has evolved and improved as an example of the disease-focused approach. This progress has involved clarifying and revising the definitions of sepsis, efforts to raise awareness, faster and more reliable laboratory tests and a host of practice-level improvements based on health services research findings and recommendations. We conclude that this multi-faceted approach incorporating elements of the ‘learning health system’ model has improved the early recognition and treatment of sepsis, and propose that this model could be productively applied to improve timely diagnosis in other time-sensitive conditions.

Diagnostic reasoning is one of the most challenging and rewarding aspects of clinical practice. As a result, facility in teaching diagnostic reasoning is a core necessity for all medical educators. Clinician educators’ limited understanding of the diagnostic process and how expertise is developed may result in lost opportunities in nurturing the diagnostic abilities of themselves and their learners. In this perspective, the authors describe their journeys as clinician educators searching for a coherent means of teaching diagnostic reasoning. They discuss the initial appeal and immediate applicability of dual process theory and cognitive biases to their own clinical experiences and those of their trainees, followed by the eventual and somewhat belated recognition of the importance of context specificity. They conclude that there are no quick fixes in guiding learners to expertise of diagnostic reasoning, but rather the development of these abilities is best viewed as a long, somewhat frustrating, but always interesting journey. The role of the teacher of clinical reasoning is to guide the learners on this journey, recognizing true mastery may not be attained, but should remain a goal for teacher and learner alike.

Background: Incident reporting systems are useful tools to raise awareness of patient safety issues associated with healthcare error, including errors associated with the medical laboratory. Methods: Previously, we presented the analysis of data compiled by the British Columbia Patient Safety & Learning System over a 3-year period. A second comparable set was collected and analyzed to determine if reported error rates would tend to remain stable or change. Results: Compared to the original set, the second set presented changes that were both materially and statistically significant. Overall, the total number of reports increased by 297% with substantial changes between the pre-examination, examination and post-examination phases (χ 2 : 993.925, DF=20; p<0.00001). While the rate of change for pre-examination (clerical and collection) errors were not significantly different than the total year results, the rate of change for reporting examination errors rose by 998%. While the exact reason for dramatic change is not clear, possible explanations are provided. Conclusions: Longitudinal error rate tracking is a useful approach to monitor for laboratory quality improvement.

Background: While there is some experimental evidence to support the use of cognitive forcing strategies to reduce diagnostic error in residents, the potential usability of such strategies in the clinical setting has not been explored. We sought to test the effect of a clinical reasoning tool on diagnostic accuracy and to obtain feedback on its usability and acceptability. Methods: We conducted a randomized behavioral experiment testing the effect of this tool on diagnostic accuracy on written cases among post-graduate 3 (PGY-3) residents at a single internal medical residency program in 2014. Residents completed written clinical cases in a proctored setting with and without prompts to use the tool. The tool encouraged reflection on concordant and discordant aspects of each case. We used random effects regression to assess the effect of the tool on diagnostic accuracy of the independent case sets, controlling for case complexity. We then conducted audiotaped structured focus group debriefing sessions and reviewed the tapes for facilitators and barriers to use of the tool. Results: Of 51 eligible PGY-3 residents, 34 (67%) participated in the study. The average diagnostic accuracy increased from 52% to 60% with the tool, a difference that just met the test for statistical significance in adjusted analyses (p=0.05). Residents reported that the tool was generally acceptable and understandable but did not recognize its utility for use with simple cases, suggesting the presence of overconfidence bias. Conclusions: A clinical reasoning tool improved residents’ diagnostic accuracy on written cases. Overconfidence bias is a potential barrier to its use in the clinical setting.

Background: Phase contrast microscopy is the recommended technique for urine sediment examination. Bright field microscopy does not differentiate objects with slight changes in the refractive index and hence phase contrast is a superior alternative. Methods: In this article, we describe a novel method to improve contrast in bright field microscopy. A strategically placed disc of specific dimensions enhances the diffraction of rays by Fresnel principle causing a shift in wavelength in the rays which are perceived as differences in contrast by the eye due to constructive and destructive interference. Results: Epithelial cells, red blood cells (RBCs), dysmorphic red blood cells, casts, bacteria and crystals are easily seen and differentiated by this technique. Conclusions: The images obtained are similar to those obtained by phase contrast microscopy.