Kilian Michael, Sherbino Jonathan, Hicks Christopher, Monteiro Sandra D
Division of Emergency Medicine, North York General Hospital, Toronto, ON, Canada.
Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.
Diagnosis (Berl). 2019 Jun 26;6(2):151-156. doi: 10.1515/dx-2018-0073.
Background Avoiding or correcting a diagnostic error first requires identification of an error and perhaps deciding to revise a diagnosis, but little is known about the factors that lead to revision. Three aspects of reflective practice, seeking Alternative explanations, exploring the Consequences of missing these alternative diagnoses, identifying Traits that may contradict the provisional diagnosis, were incorporated into a three-point diagnostic checklist (abbreviated to ACT). Methods Seventeen first and second year emergency medicine residents from the University of Toronto participated. Participants read up to eight case vignettes and completed the ACT diagnostic checklist. Provisional and final diagnoses and all responses for alternatives, consequences, and traits were individually scored as correct or incorrect. Additionally, each consequence was scored on a severity scale from 0 (not severe) to 3 (very severe). Average scores for alternatives, consequences, and traits and the severity rating for each consequence were entered into a binary logistic regression analysis with the outcome of revised or retained provisional diagnosis. Results Only 13% of diagnoses were revised. The binary logistic regression revealed that three scores derived from the ACT tool responses were associated with the decision to revise: severity rating of the consequence for missing the provisional diagnosis, the percent correct for identifying consequences, and the percent correct for identifying traits (χ2 = 23.5, df = 6, p < 0.001). The other three factors were not significant predictors. Conclusions Decisions to revise diagnoses may be cued by the detection of contradictory evidence. Education interventions may be more effective at reducing diagnostic error by targeting the ability to detect contradictory information within patient cases.
背景 避免或纠正诊断错误首先需要识别错误，或许还需要决定修正诊断，但对于导致诊断修正的因素却知之甚少。反思性实践的三个方面，即寻求其他解释、探究遗漏这些替代诊断的后果、识别可能与临时诊断相矛盾的特征，被纳入一个三点诊断清单（简称为ACT）。方法 来自多伦多大学的17名急诊医学一年级和二年级住院医师参与了研究。参与者阅读了多达8个病例 vignettes，并完成了ACT诊断清单。临时诊断和最终诊断以及关于替代诊断、后果和特征的所有回答分别被评定为正确或错误。此外，每个后果都根据严重程度从0（不严重）到3（非常严重）进行评分。将替代诊断、后果和特征的平均得分以及每个后果的严重程度评分纳入二元逻辑回归分析，以修正或保留临时诊断为结果变量。结果 只有13%的诊断被修正。二元逻辑回归显示，从ACT工具回答中得出的三个得分与诊断修正的决定相关：遗漏临时诊断后果的严重程度评分、识别后果的正确百分比以及识别特征的正确百分比（χ2 = 23.5，自由度 = 6，p < 0.001）。其他三个因素不是显著的预测因素。结论 诊断修正的决定可能由矛盾证据的发现所引发。教育干预通过针对在患者病例中检测矛盾信息的能力，可能在减少诊断错误方面更有效。
