ﺑﺳم ﷲ اﻟرﺣﻣن اﻟرﺣﯾم Diagnostic safety in the State of Qatar Successes & Challenges Wanis H Ibrahim FRCP (Edin), FRCP (Glasg), FRCP (Ire), FCCP, F (Pulm) Senior Consultant Physician Hamad General Hospital Professor of Clinical Medicine Qatar University & Weill-Cornell –Qatar Doha/Qatar
I have no conflict of interest to disclose
Objectives • Successes in diagnostic safety in the State of Qatar (HMC) • Challenges in providing a safe diagnostics
Case of Mrs. M From old HMC medical records Mrs. M, a 46-year-old presented to one of the HMC hospitals ED in a very busy night complaining from right upper abdominal pain. The pain was severe and preventing her from taking deep breath. She was assessed by an ED junior doctor who was suspecting acute cholecystitis because of tender RHC with a positive Murphy’s sign. Patient did not have leukocytosis or fever. US abdomen showed a suspicion of GB polyp. GS resident on call was consulted. He ordered HIDA scan. Second day while in ED, patient’s daughter informed the nurse that her mother’s breathing was not normal. Another ED physician who did not receive endorsement from the previous colleague found the patient to be hypotensive with low O2 saturation. A suspicion of septic shock was made and fluid resuscitation/antibiotics were administered. The assigned nurse noticed that the patient's right leg was swollen. A senior ED physician evaluated the patient and suspected a pulmonary embolism causing a referred RHC pain. An urgent CTPA (which was delayed for 6 hours) confirmed a massive pulmonary embolism with a right pulmonary infarction. Patient was admitted to ICU because of hypoxemic respiratory failure and hypotension and received thrombolytic therapy. Q1. What factors were responsible for the delay in diagnosis of this patient? Q2. What risks were/could have been encountered because of delayed PE diagnosis?
• Comprehensive reforms in health care system. • Comprehensive World-Class Healthcare System - 2030
Goals for improving diagnosis & reducing diagnostic errors Facilitate more effective teamwork in the diagnostic process among health care • professionals, patients, and their families Enhance health care professional education and training in the diagnostic process • Ensure that health information technologies support patients and health care • professionals in the diagnostic process Provide correct approaches of minimizing diagnostic errors through teaching and • education (Not punitive/threatening approaches) Establish a work system and culture that supports the diagnostic process and • improvements in diagnostic performance Develop a reporting environment and medical liability system that facilitates • improved diagnosis by learning from diagnostic errors and near misses Design a payment and care delivery environment that supports the diagnostic • process Provide dedicated funding for research on the diagnostic process and diagnostic • errors The National Academies of Sciences, Engineering and Medicine. Improving Diagnosis in Health Care (2015). The National Academies Press, Washington, DC. www.nap.edu
Clinician process in diagnosis v Clinician process and team work is one of the most crucial steps to achieve a reliable diagnosis. v Diagnosis remains fundamentally dependent on: A personal interaction of a • [clinician] with a patient The sufficiency of communication • between them The accuracy of the patient’s • history and physical examination, and The cognitive energy necessary to • synthesize a vast array of information” Kassirer, J. P. 2014. Imperatives, expediency, and the new diagnosis. Diagnosis 1(1):11–12.
Proficiency in clinical reasoning • Clinical reasoning: is “the cognitive process that is necessary to evaluate and manage a patient’s medical problems” • Accurate, timely, and patient-centered diagnosis relies heavily on proficiency in clinical reasoning , which is often regarded as the clinician’s quintessential competency. Barrows HS, Tamblyn RM. Problem-based learning. An approach to medical education. New York: Springer; 198
Changes in medical team structure (HMC) Shift from consultant-led service • to consultant-delivered service Consultants are available 24 • hours in-house Consultants are required to • counter-sign all resident entries Consultants are required to • document their own notes at patient’s admission and at least twice per week. Continuous consultant • supervision of junior doctors during in-patient and out-patient services
Enhancing Health Care Professional Education and Training in the Diagnostic Process & clinical reasoning at HMC Lack of focus on developing clinical • reasoning and understanding the cognitive contributions to decision making represents a major gap in education within all health care professions. Doctors-in-training at HMC are • required to pass strict clinical exams that test their diagnostic & clinical reasoning abilities Clinical courses are regularly • conducted to improve diagnostic and clinical reasoning abilities among physicians-in-training at HMC
Inter-professional collaboration & patient engagement • Regular organization of Multidisciplinary Team (MDT) Care Meetings and Rounding at HMC • Use of standardized communication techniques for critical information (SBAR) • Communication training courses • MDT – Patient/family meetings • Second opinion availability • Patient access to electronic health records, including clinical notes and diagnostic testing results • HMC clinical guidelines and policies
Clinical guidelines and policies (HMC)
Improvement in Health Information Technologies at HMC • Health IT has the potential to improve diagnosis and reduce diagnostic errors by facilitating timely and easy access to information; communication among health care professionals, patients, and their families; clinical reasoning; and feedback and follow-up in the diagnostic process.
Improvement in Laboratory services (HMC) • The laboratory has state-of-the-art testing facilities • The laboratory provides timely, accurate and appropriate pathology services in support of patient care. • Results of urgent tests, such as those from the emergency department, operating theatres, and intensive care units, are given special attention and reported in a very short time • Point of Care Testing, which is testing at or near the site of patient care, is available • The laboratory department is accredited by CAP
Histopathology specimens All surgical pathology reports are released in an appropriate and timely manner in order to achieve • high standards in patient care. • Turnaround time (TAT) is as measured in working days from the time the specimen is received in the laboratory to the time the verbal report is available or the final report is released. In measurement of TAT, Specimens requiring more tests, prolonged fixation, decalcification, special • stains, immunohistochemistry, outside consultation will require longer turnaround time. • TAT for STAT tests: • Frozen Section 20 minutes/block (90% threshold) • "Renal Transplant biopsy Preliminary Report within 24 – 48 hours " TAT for routine tests: • GI Biopsies / Liver 3 days Renal biopsy 5 days All tissue specimens (biopsied, small and medium size resection) 5 day Large specimen or extra fixative 7 days Bone 10 days • Critical values such as cancer cases are reported to focal point to contact the requesting physician
Improvement in Radiology services • All state-of-art radiologic facilities including both diagnostic and interventional radiology services are available at HMC • Urgent cases and cancer cases are given priority • In-patient: Preliminary report is available in few hours Final report in 48 hours • Out-patient: Non-urgent: final report in 5 days • Red flags/critical results are immediately reported to a focal point to contact the treating physician
Monitoring of the diagnostic process • Conducting analyses of HMC diagnostic errors, near • Quality improvement misses, and adverse events programs presents the best • Patient safety programs opportunity to learn from • Supervision monitoring such experiences and • Monitoring adherence to implement changes to HMC policies & guidelines improve diagnosis. • Adverse event reporting Provide safe environments, • without the threat of legal • Morbidity & Mortality MDT discovery or disciplinary action, to analyze and learn from these events.
Shortage in diagnostic research • Despite the tremendous improvement in clinical research in the State of Qatar, diagnosis and diagnostic errors are not a focus of HMC research efforts. Research at HMC is usually disease-focused.
Collaboration among health care facilities • The diagnostic process hinges on successful intra- and inter-professional collaboration among health care professionals, including primary care clinicians, physicians in various specialties, nurses, pharmacists, technologists, therapists, social workers, patient navigators, and many others. • Although such collaboration exists among HMC tertiary care facilities, there is significant shortage in coordination between primary care and tertiary care centers
Recommend
More recommend
