A clinical reasoning curriculum for medical students: an interim analysis

Objectives Diagnostic error is a critical patient safety issue that can be addressed in part through teaching clinical reasoning. Medical schools with clinical reasoning curricula tend to emphasize general reasoning concepts (e.g., differential diagnosis generation). Few published curricula go beyond teaching the steps in the diagnostic process to address how students should structure their knowledge to optimize diagnostic performance in future clinical encounters or to discuss elements outside of individual cognition that are essential to diagnosis. Methods In 2016, the University of California, San Francisco School of Medicine launched a clinical reasoning curriculum that simultaneously emphasizes reasoning concepts and intentional knowledge construction; the roles of patients, families, interprofessional colleagues; and communication in diagnosis. The curriculum features a longitudinal thread beginning in first year, with an immersive three week diagnostic reasoning (DR) course in the second year. Students evaluated the DR course. Additionally, we conducted an audit of the multiyear clinical reasoning curriculum using the Society to Improve Diagnosis in Medicine-Macy Foundation interprofessional diagnostic education competencies. Results Students rated DR highly (range 4.13–4.18/5 between 2018 and 2020) and reported high self-efficacy with applying clinical reasoning concepts and communicating reasoning to supervisors. A course audit demonstrated a disproportionate emphasis on individual (cognitive) competencies with inadequate attention to systems and team factors in diagnosis. Conclusions Our clinical reasoning curriculum led to high student self-efficacy. However, we stressed cognitive aspects of reasoning with limited instruction on teams and systems. Diagnosis education should expand beyond the cognitive- and physician-centric focus of most published reasoning courses.

Cancellations and Transfers Related to New-Onset Atrial Fibrillation: An Analysis of Survey and Patient Safety Reporting Data From Ambulatory Surgical Facilities

Atrial fibrillation (AF) is a cardiac arrhythmia characterized by an irregular rhythm and often rapid heart rate. People with AF can be symptomatic or asymptomatic and are at increased risk for stroke. In this study, we used two data sources—a survey and Pennsylvania Patient Safety Reporting System (PA-PSRS) reports—to examine new-onset AF in Pennsylvania ambulatory surgical facilities (ASFs). The survey was developed and conducted to learn more about new-onset AF– related cancellations and transfers in Pennsylvania ASFs and to update the Patient Safety Authority ASF Cancellation and Transfer Tracking Tool. The survey response rate was 53.1%, with 50.9% of respondents indicating new-onset AF–related cancellations in the last year. A five-year review of PA-PSRS data revealed an increase in the number of new-onset AF–related cancellation and transfer events that occurred in the last two years. In 70.9% of the reports, patients were 65 years of age and older. A paucity of research on this patient safety issue led us to identify areas for future research.

Using an electronic discharge notification system reduces the time delay between discharge and a summary being sent to the GP

AimsAll patients discharged from our Paediatric Liaison Team will have an electronic discharge summary sent to their GP within 24 hours by January 2020.BackgroundWriting a GP discharge summary is an essential part of patient care and is a patient safety issue if not completed on time. The NHS England Standard Contract states discharge summaries should be completed and sent to a GP within 24 hours of discharge. Baseline data showed our median time between discharge and a GP summary being sent off as 3 days and a baseline survey of staff in our team rated our discharge summary process as inefficient and time consuming. At baseline our discharge summary was typed on a word document which was then emailed to admin staff who would print and post to the GP. Our electronic patient record had an inbuilt discharge notification function that generates and sends summaries via email to the GP that other teams in the trust were already using.MethodWe utilised the Model for Improvement Quality Improvement methodology. Initially we created a driver diagram breaking the process of discharge summary writing into its constituent components to generate change ideas. We then tested out these out in plan, do, study, act (PDSA) cycles whilst continually collecting data using a shared team spreadsheet to monitor for change.ResultWe found that switching to electronically sent discharge notifications improved our time from discharge to a summary being sent to the GP from a median of 3 days to 1 day. We noticed that alongside a shared team spreadsheet monitoring when summaries were written we also reduced variation of time between discharge and a summary from a range of 0-27 days (with an outlier of 161) to 0-9 days.ConclusionOn average the time from discharge to a summary being written met the standard and we reduced the variability of time delay by using an electronic notification. However only 56% of summaries were sent within the 24 hour limit. Key factors for continued variability identified during regular team meetings included overall caseload of patients, amount of staff on shift and technical issues with the form. Our plan for sustainability is to discuss monthly in the team meeting any discharges that took longer than 1 day and target further PDSA cycles to these issues.

Visual Analytics in Delirium Management

Background: Delirium is a patient safety issue that often occurs within the population of elderly people. As delirium may be characterized by fluctuating progress, the aim of this work is to find methods to visualize the occurrence of delirium over time in different patient stays in gerontopsychatric settings. Methods: We analyzed current data mining visualization techniques for clinical research using a delirium data set collected in a gerontopsychatric setting. Results: We identified heatmaps and dendrograms resulting from hierarchical clustering as a suitable visualization method. Conclusion: Heat maps with hierarchical clustering are a suitable data mining tool or visualization technique to study delirium cases in the time course of patient stays.

Automatic Analysis of ACR Phantom Images in MRI

Background: Quality Assurance (QA) of Magnetic Resonance Imaging (MRI) system is an essential step to avoid problems in diagnosis when image quality is low. It is considered a patient safety issue. The accreditation program of the American College of Radiology (ACR) includes a standardized image quality measurement protocol. However, it has been shown that human testing by visual inspection is not objective and not reproducible. Methods: The overall goal of the present paper was to develop and implement a fully automated method for accurate image analysis to increase its objectivity. It can positively impact the QA process by decreasing the reaction time, improving repeatability, and by reducing operator dependency. The proposed QA procedures were applied to ten clinical MRI scanners. The performance of the automated procedure was assessed by comparing the test results with the decisions made by trained MRI technologists according to ACR guidelines. The p-value, correlation coefficient of the manual and automatic measurements were also computed using the Pearson test. Result and Conclusion: Compared to the manual process, the use of the proposed approach can significantly reduce the time requirements while maintaining consistency with manual measurements and furthermore, decrease the subjectivity of the results. Accordingly, a strong correlation was found and the corresponding p-value was much lower than the significance level of 0.05 indicating a good agreement between the two measurements.

Recent Warnings about Antihypertensive Drugs and Cancer Risk: Where Do They Come From?

The recent decrease in mortality related to cardiovascular diseases has largely been due to the more effective treatment of cardiovascular risk factors and secondary prevention therapies. More people than ever are now on long-term medications. Hypertension, which is one of the most common cardiovascular risk factors, requires life-long treatment. Recent evidence has focused attention on the risk of cancer that may be associated with the long-term use of antihypertensive therapy. This article summarises available evidence surrounding three recent events in this setting. Even though this is a crucial patient safety issue, there are no conclusive answers at this time and further studies are required.