Article

Diagnostic errors and reflective practice in medicine

Innovare Institute, Fortaleza, Ceará, Brazil.
Journal of Evaluation in Clinical Practice (Impact Factor: 1.58). 03/2007; 13(1):138-45. DOI: 10.1111/j.1365-2753.2006.00638.x
Source: PubMed

ABSTRACT Adverse effects of medical errors have received increasing attention. Diagnostic errors account for a substantial fraction of all medical errors, and strategies for their prevention have been explored. A crucial requirement for that is better understanding of origins of medical errors. Research on medical expertise may contribute to that as far as it explains reasoning processes involved in clinical judgements. The literature has indicated the capability of critically reflecting upon one's own practice as a key requirement for developing and maintaining medical expertise throughout life.
This article explores potential relationships between reflective practice and diagnostic errors.
A survey of the medical expertise literature was conducted. Origins of medical errors frequently reported in the literature were explored. The potential relationship between diagnostic errors and the several dimensions of reflective practice in medicine, brought to light by recent research, were theoretically explored.
Uncertainty and fallibility inherent to clinical judgements are discussed. Stages in the diagnostic reasoning process where errors could occur and their potential sources are highlighted, including the role of medical heuristics and biases. The authors discuss the nature of reflective practice in medicine, and explore whether and how the several behaviours and reasoning processes that constitute reflective practice could minimize diagnostic errors. Future directions for further research are discussed. They involve empirical research on the role of reflective practice in improving clinical reasoning and the development of educational strategies to enhancing reflective practice.

2 Followers
 · 
243 Views
  • Source
    • "Clinical reasoning results from the interpretation of data by a specific clinician faced with a specific situation (a specific patient within a specific context presenting with a specific constellation of signs and symptoms). The clinician brings to each encounter his/her own knowledge, skills, beliefs, and perspectives which influence his/her perception and interpretation of data (Mamede et al. 2007). The result of clinical reasoning is not necessarily a precise diagnosis. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Clinical reasoning is the cornerstone of medical practice. To date, there is no established framework regarding clinical reasoning difficulties, how to identify them, and how to remediate them. Aim: To identify the most common clinical reasoning difficulties as they present in residents' patient encounters, case summaries, or medical notes. To develop a guide to support medical educators' process of educational diagnosis and management in this area. Methods: We used a participatory action research method. We carried out eight iterative reflective cycles with a group of clinical teachers. The repeated phases of experimentation and observation were conducted by participants in their own clinical teaching setting. Our findings were tested and validated on both an individual and collective basis Results: We found five categories of clinical reasoning difficulties as they present in the clinical teaching settings. We identified indicators for each. Indicators may be different depending on the type of supervision. These findings were assembled and organized to construct a guide for clinical teachers. Conclusions: The guide should assist clinical teachers in detecting clinical reasoning difficulties during clinical teaching and in providing remediation that is tailored to the specific difficulty identified. Its development furthers our understanding of clinical reasoning difficulties and provides a useful tool.
    Medical Teacher 12/2012; DOI:10.3109/0142159X.2012.733041 · 2.05 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Missed or delayed diagnoses are a com- mon but understudied area in patient safety research. To better understand the types, causes, and prevention of such errors, we surveyed clinicians to solicit perceived cases of missed and delayed diagnoses. Methods: A 6-item written survey was administered at 20 grand rounds presentations across the United States and by mail at 2 collaborating institutions. Respondents were asked to report 3 cases of diagnostic errors and to describe their perceived causes, seriousness, and frequency. Results: A total of 669 cases were reported by 310 clini- cians from 22 institutions. After cases without diagnostic errors or lacking sufficient details were excluded, 583 re- mained. Of these, 162 errors (28%) were rated as major, 241 (41%) as moderate, and 180 (31%) as minor or insig- nificant. The most common missed or delayed diagnoses werepulmonaryembolism(26cases(4.5%oftotal)),drug reactions or overdose (26 cases (4.5%)), lung cancer (23 cases (3.9%)), colorectal cancer (19 cases (3.3%)), acute coronary syndrome (18 cases (3.1%)), breast cancer (18 cases (3.1%)), and stroke (15 cases (2.6%)). Errors oc- curred most frequently in the testing phase (failure to or- der, report, and follow-up laboratory results) (44%), fol- lowed by clinician assessment errors (failure to consider andoverweighingcompetingdiagnosis)(32%),historytak- ing(10%),physicalexamination(10%),andreferralorcon- sultation errors and delays (3%). Conclusions:Physicians readily recalled multiple cases of diagnostic errors and were willing to share their ex- periences. Using a new taxonomy tool and aggregating cases by diagnosis and error type revealed patterns of di- agnostic failures that suggested areas for improvement. Systematic solicitation and analysis of such errors can identify potential preventive strategies. Arch Intern Med. 2009;169(20):1881-1887
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Inleiding Het noodzakelijke denkproces voor het nemen van de juiste beslissingen tijdens het praktische, fysiotherapeutische handelen wordt klinisch redeneren genoemd. In het algemeen wordt aangenomen dat flexibiliteit in het denkproces en een goed gestructureerde kennisbasis hieraan ten grondslag liggen. Vraagstelling Dit onderzoek is gericht op de vraag of in de perceptie van de studenten het competentiegericht onderwijs (CGO), ingericht volgens het 4 C/ID-model, het klinisch redeneren binnen de domeinen flexibiliteit in het denkproces en kennisstructuur, meer bevordert dan het meer traditionele, probleemgestuurde onderwijs (PGO). Methode Aan de hand van een vragenlijst die het klinisch redeneren in kaart brengt (met subschalen in de domeinen flexibiliteit in het denkproces en kennisstructuur), zijn vierdejaars studenten van het cohort 2004 (n=58) en van het cohort 2006 (n=34) van de opleiding Fysiotherapie van de Hogeschool Zuyd te Heerlen met elkaar vergeleken. Daarbij werd een ongepaarde student t-toets uitgevoerd. Resultaten Het resultaat van dit onderzoek laat zien dat in de perceptie van de studenten een statistisch significante verbetering is opgetreden in het klinisch redeneren van de vierdejaars studenten uit het cohort 2006 die het CGO volgden in vergelijking met studenten uit het cohort 2004 die het meer traditionele PGO doorliepen (klinisch redeneren p=0.01 en meer specifiek in het domein flexibiliteit in denken p=0.01 en kennisstructuur p=0.03). Conclusie en discussie Meer onderzoek is nodig naar de wijze waarop CGO het klinisch redeneren van studenten helpt verbeteren, naar de factoren die dit proces mede beïnvloeden en naar objectieve meetinstrumenten om het klinisch redeneren te kunnen evalueren. (Gerards-Last D, Geraets J. Klinisch redeneren in het fysiotherapie onderwijs. Tijdschrift voor Medisch Onderwijs 2011;30(5):226-236.)
    Tijdschrift voor Medisch Onderwijs 05/2011; 30(5). DOI:10.1007/s12507-011-0053-5
Show more