Description
Diagnostic error in acute care represents an unresolved safety issue. We are using the Safer Dx framework to identify research questions across sociotechnical work system and diagnostic process dimensions. During problem analysis, we are utilizing systems engineering and human factors methods to analyze cases, understand stakeholders’ perspectives of diagnostic error, and validate potential risk factors and previously described electronic events. We will use the knowledge generated from these activities to design and develop an intervention that proactively identifies patients at risk for diagnostic error.
Learning Objective: After participating in this session, the learner should be better able to:
1. Understand the scope of the patient safety issues related to diagnostic error in acute care
2. Understand an approach for analyzing the problem of diagnostic error in the acute care setting, including use of systems engineering and human factors methodologies
3. Understand the concept of electronic events (e.g., "e-triggers") to identify cases of diagnostic error
4. Understand how to core activities during the problem analysis phase will help formulate an approach to designing and developing an intervention to address key diagnostic process failure points.
Authors:
Anuj Dalal (Presenter)
Brigham and Women's Hospital
Kumiko Schnock, Brigham and Women's Hospital
Nicholas Piniella, Brigham and Women's Hospital
Kerrin Bersani, Brigham and Women's Hospital
Pamela Garabedian, Brigham and Women's Hospital
Kevin Carr, Brigham and Women's Hospital
Ronen Rozenblum, Brigham and Women's Hospital
Stuart Lipsitz, Brigham and Women's Hospital
Jacqueline Griffin, Northeastern University
Jeffrey Schnipper, Brigham and Women's Hospital
David Bates, Brigham and Women's Hospital
Presentation Materials: