This paper provides an opportunity to retrieve, analyze, and evaluate real-world errors in healthcare. In response to these adverse events, the student assumes the perspective of an institution’s risk manager by analyzing causal and contributing factors
This paper provides an opportunity to retrieve, analyze, and evaluate real-world errors in healthcare. In response to these adverse events, the student assumes the perspective of an institution’s risk manager by analyzing causal and contributing factors and proposing mitigating factors as safety tenets for adoption by the institution. Students will apply critical thinking, problem-solving, writing skills, and quality and safety principles in healthcare.
Compose a five to six-page paper with the following sections:
Find three legal cases that involve negligence in the healthcare setting. Based on the details of what went wrong in these cases, develop a prevention plan to mitigate risk.
Be sure to include a definition of negligence in the introduction (cite this).
Write at least one page of content for each case:
Describe one of the ethical principles that were violated.
Describe one of the regulations or standards of practice that was violated.
Include at least three preventive measures for each case.
How could the injuries or negative outcomes in these cases be prevented? What actions do you recommend for health care professionals or health care organizations? If you were the director of a facility what new policies/administrative actions would you implement to mitigate this risk.
Provide reasoning for your recommendations.
Provide at least 4 citations, including the textbook.
Provide a paper introduction and conclusion in your paper.
Each Section must be a minimum of ½ page and a maximum of one full page. The paper should be a minimum of five and a maximum of six pages with the title page and reference page.
Overview of Diagnostic Error in Health Care
This chapter explains the committee’s definition of diagnostic error, describes the committee’s approach to measurement, and reviews the available information about the epidemiology of diagnostic error.
The committee proposes five purposes for measurement: to establish the incidence and nature of the problem of diagnostic error; to determine the causes and risks of diagnostic error; to evaluate interventions; for education and training purposes; and for accountability purposes.
Because diagnostic errors have been a very challenging area for measurement, the current focus of measurement efforts has been on understanding the incidence and nature of diagnostic error and determining the causes and risks of diagnostic error.
The committee highlighted the way in which various measurement approaches could be applied to develop a more robust understanding of the epidemiology of diagnostic error and the reasons that these errors occur.
DEFINITION OF DIAGNOSTIC ERROR
The Institute of Medicine (IOM) has defined quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990, p. 5). The IOM’s report Crossing the Quality Chasm further elaborated on high-quality care by identifying six aims of quality: “[H]ealth care should be (1) safe—avoiding injuries to patients from the care that is intended to help them; (2) effective—providing services based on scientific knowledge to all who could ben-
Suggested Citation:”3 Overview of Diagnostic Error in Health Care.” National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.×
efit and refraining from providing services to those not likely to benefit; (3) patient-centered—providing care that is respectful of and responsive to individual preferences, needs, and values, and ensuring that patient values guide all clinical decisions; (4) timely—reducing waits and sometimes harmful delays for both those who receive and those who give care; (5) efficient—avoiding waste, including waste of equipment, supplies, ideas, and human resources; and (6) equitable—providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geography, and socioeconomic status” (IOM, 2001, p. 6).
Communicating accurate and timely diagnoses to patients is an important component of providing high-quality care; errors in diagnosis are a major threat to achieving high-quality care.
The IOM defines an error in medicine to be the “failure of a planned action to be completed as intended (i.e., error of execution) and the use of a wrong plan to achieve an aim (i.e., error of planning) [commission]” (IOM, 2004, p. 30).
The definition also recognizes the failure of an unplanned action that should have been completed (omission) as an error (IOM, 2004).
The IOM report To Err Is Human: Building a Safer Health System distinguished among four types of error: diagnostic, treatment, preventive, and other (see Box 3-1).
An adverse event is “an event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient” (IOM, 2004, p. 32).
The committee’s deliberations were informed by a number of existing definitions and definitional frameworks on diagnostic error (see Appendix C). For instance, Graber and colleagues used a classification of error from the Australian Patient Safety Foundation to define diagnostic error as a “diagnosis that was unintentionally delayed (sufficient information was available earlier), wrong (another diagnosis was made before the correct one), or missed (no diagnosis was ever made), as judged from the eventual appreciation of more definitive information” (Graber et al., 2005, p. 1493).
They further divided diagnostic error into three main categories: no-fault errors, system-related errors, and cognitive errors. No-fault errors, originally described by Kassirer and Kopelman (1989), stem from factors outside the control of the clinician or the health care system, including atypical disease presentation or patient-related factors such as providing misleading information.
The second category, system-related errors, can include technical or organizational barriers, such as problems with communication and care coordination; inefficient processes; technical failures; and equipment problems. Finally, there are cognitive errors that clinicians may make.
National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794.