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Diagnostic Errors Is A Threat To Patient Safety Term Paper

Introduction Lack of time and sufficient resources have led to diagnostic errors. Cognitive biases of clinicians, underlying problems with healthcare systems, poor teamwork and communication, lack of reliable medical systems have been attributed to missed and delayed diagnoses in the healthcare sector. Doctors formulate ‘working diagnoses’ when patients are admitted to hospitals. Although a diagnosis is uncertain at this point, doctors treat the patient as if the working diagnosis is precise. The working diagnoses are confirmed when a patient improves after a few days of treatment, otherwise the doctors have to consider whether it was wrong (Lambe et al., 2016). However, the time taken to make the right diagnosis through trial and error greatly reduces the patient’s chance of surviving. Little consideration is given to how doctors make diagnoses and refines them to come up with treatment plans for their patients. Physicians require enough time to run correct diagnoses, make the right treatment plans and reviews. Moreover, patients, their families and the society at large haven’t been informed about this impending problem in healthcare practice (AHQR, 2017).

Background and Body

Although many studies on patient safety have cited the prominence of diagnostic errors in the medical field, the practice has received less attention. According to a Harvard Medical Practice Study, errors during diagnosis are responsible for 17% of avoidable errors in patients who have been admitted (Brennan et al., 1991). Moreover, a systematic review of various autopsy research studies conducted over 40 years found that about 9% of patients have undergone a critical error during diagnosis that wasn’t even detected before the demise of the patient. Conclusively, the studies indicate that thousands of patients worldwide die annually as a result of diagnostic errors. A good example, according to a research body, is in the cognitive psychology field where clinicians use heuristics (rule of thumb or shortcuts) to make patient diagnosis based...

Although heuristics are important and ubiquitous, various studies have classified the common types of errors clinicians make as a result of using heuristics in patient diagnosis (AHQR, 2017; Sing, 2013).
Evidence-based healthcare is focused on providing ways in which prevailing research evidence can be implemented conscientiously and judiciously in the detection, prevention and treatment of healthcare disorders. However, this aim can only be ambitious due to the slow manner in which new treatments are released into practice and how practitioners are slow to eliminating or withdrawing established treatments that have been in use for better alternatives based on research findings. There are many barriers to implementing research findings on diagnostic errors into practice. Poor access to guidelines and best evidence, research size and complexity, organizational barriers, difficulties in developing evidence-based clinical policy, ineffective continuing education programs, and low patient adherence to treatments have been attributed to poor implementation of evidence-based practice. Lack of resources, time and motivation of clinicians and other stakeholders, including their attitude towards change are other barriers to implementation (Brennan et al.,; AHQR, 2017).

There are many ways to overcome the barriers to implementation of research findings into practice for improved patient safety and general care. Services that abstract information for synthesis should be used to address the problem of research size and complexity. Information systems that integrate patient care with guidelines and evidence can help foster the development of evidence-based clinical policies. Stakeholders in the industry should also develop guidelines to govern how evidence-based clinical guidelines are developed. Improvement of practitioner programs and the quality and effectiveness of education can improve access to guidelines and best evidence from studies. It is also important to develop effective strategies to motivate and encourage patients…

Sources used in this document:

References

Brennan TA ; Newhouse JP; et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991; 324: 377-384

Lambe KA ; O'Reilly G ; Kelly BD; et al. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf. 2016; 25: 808-820

Resources Related to Diagnostic Errors. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/diagnostic-safety/resources.html

Shojania KG ; Burton EC ; McDonald KM; et al. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003; 289: 2849-2856

Singh, H. (2013). Diagnostic errors: moving beyond “no respect” and getting ready for prime time. BMJ Quality & Safety, 22(10), 789–792. http://doi.org/10.1136/bmjqs-2013-002387


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