Plymouth, MA, USA.
ATW Health Solutions, Chicago, IL, USA.
Diagnosis (Berl). 2024 Sep 3;11(4):353-368. doi: 10.1515/dx-2024-0102. eCollection 2024 Nov 1.
Diagnostic errors comprise the leading threat to patient safety in healthcare today. Learning how to extract the lessons from cases where diagnosis succeeds or fails is a promising approach to improve diagnostic safety going forward. We present up-to-date and authoritative guidance on how the existing approaches to conducting root cause analyses (RCA's) can be modified to study cases involving diagnosis. There are several diffierences: In cases involving diagnosis, the investigation should begin immediately after the incident, and clinicians involved in the case should be members of the RCA team. The review must include consideration of how the clinical reasoning process went astray (or succeeded), and use a human-factors perspective to consider the system-related contextual factors in the diagnostic process. We present detailed instructions for conducting RCA's of cases involving diagnosis, with advice on how to identify root causes and contributing factors and select appropriate interventions.
诊断错误是当今医疗保健中对患者安全的主要威胁。学习如何从诊断成功或失败的案例中吸取教训，是提高诊断安全性的一个很有前途的方法。我们提供了最新和权威的指导，介绍如何修改现有的根本原因分析（RCA）方法来研究涉及诊断的案例。有几个不同之处：在涉及诊断的案例中，调查应在事件发生后立即开始，并且参与该案例的临床医生应成为 RCA 团队的成员。审查必须包括考虑临床推理过程是如何出错（或成功）的，并使用人为因素的观点来考虑诊断过程中的系统相关背景因素。我们提供了详细的指导，用于对涉及诊断的案例进行 RCA，并就如何确定根本原因和促成因素以及选择适当的干预措施提供了建议。
