I am an academic internist focused on reducing harm from diagnostic error. My work involves health services research in this area, leading the Society to Improve Diagnosis in Medicine, and serving as co-Editor in Chief of the journal DIAGNOSIS.
Journal of the American Society of Nephrology, 1991
The urinary sediment was examined by light microscopy in 65 consecutive inpatients with renal ins... more The urinary sediment was examined by light microscopy in 65 consecutive inpatients with renal insufficiency (not due to pre- or postrenal factors) referred to a nephrology consult service for evaluation. In the 60 patients in whom a single diagnosis was reached, the sediments of 34 (57%) contained an easily recognized cell, which we have called the "bubble cell". These cells were bizarre, large cells with a single nucleus, which appeared to contain one or more fluid-filled vesicles. Bubble cells were most prevalent in the sediment of patients with acute tubular necrosis but were also seen a variety of other renal diseases. In most patients with acute tubular necrosis, the sediment also contained "normal"-appearing renal tubular cells, muddy brown casts, and oval fat bodies which were indistinguishable from those seen in the nephrotic syndrome. By electron microscopy, the bubble cells appeared to be vacuolated renal tubular epithelial cells, which had characterist...
Objectives Improving diagnosis-related education in the health professions has great potential to... more Objectives Improving diagnosis-related education in the health professions has great potential to improve the quality and safety of diagnosis in practice. Twelve key diagnostic competencies have been delineated through a previous initiative. The objective of this project was to identify the next steps necessary for these to be incorporated broadly in education and training across the health professions. Methods We focused on medicine, nursing, and pharmacy as examples. A literature review was conducted to survey the state of diagnosis education in these fields, and a consensus group was convened to specify next steps, using formal approaches to rank suggestions. Results The literature review confirmed initial but insufficient progress towards addressing diagnosis-related education. By consensus, we identified the next steps necessary to advance diagnosis education, and five required elements relevant to every profession: 1) Developing a shared, common language for diagnosis, 2) deve...
The IOM report ‘Improving Diagnosis in Health Care’ represents a major advance in summarizing the... more The IOM report ‘Improving Diagnosis in Health Care’ represents a major advance in summarizing the problem of diagnostic error. Three new concepts in the report will be helpful in future efforts to understand and improve the diagnostic process: a new definition of diagnostic error, a new framework for understanding the diagnostic process, and a new concept of the diagnostic ‘team’. This paper highlights these new concepts and their relevance to improving diagnosis.
Crew Resource Management (CRM) training includes teamwork, communication, decision making, and th... more Crew Resource Management (CRM) training includes teamwork, communication, decision making, and the routine usage of checklists and protocols. The principles of CRM were developed in high-risk, high-reliability industries where mistakes cause disastrous consequences. In recent years, CRM practices have been introduced to hospitals to improve patient safety. This paper examines the role of debriefing in the operating room, in helping to make the surgical suite safer for patients. As one of CRM’s most powerful tools, debriefing improves communication across disciplines, provides a means for practice improvement, and assures that equipment, personnel, and technology issues are identified and addressed. Communication among professionals in the operating room and the practice of debriefing will be discussed through an examination of the experience of the anesthesia and surgical teams at Memorial Regional Hospital and Joe DiMaggio Children’s Hospital in Hollywood, Florida. It was found tha...
BackgroundErrors in reasoning are a common cause of diagnostic error. However, it is difficult to... more BackgroundErrors in reasoning are a common cause of diagnostic error. However, it is difficult to improve performance partly because providers receive little feedback on diagnostic performance. Examining means of providing consistent feedback and enabling continuous improvement may provide novel insights for diagnostic performance.MethodsWe developed a model for improving diagnostic performance through feedback using a six-step qualitative research process, including a review of existing models from within and outside of medicine, a survey, semistructured interviews with individuals working in and outside of medicine, the development of the new model, an interdisciplinary consensus meeting, and a refinement of the model.ResultsWe applied theory and knowledge from other fields to help us conceptualise learning and comparison and translate that knowledge into an applied diagnostic context. This helped us develop a model, the Diagnosis Learning Cycle, which illustrates the need for cli...
Background Communication failures involving test results contribute to issues of patient harm and... more Background Communication failures involving test results contribute to issues of patient harm and sentinel events. This article aims to synthesise review evidence, practice insights and patient perspectives addressing problems encountered in the communication of diagnostic test results. Methods The rapid review identified ten systematic reviews and four narrative reviews. Five practitioner interviews identified insights into interventions and implementation, and a citizen panel with 15 participants explored the patient viewpoint. Results The rapid review provided support for the role of technology to ensure effective communication; behavioural interventions such as audit and feedback could be effective in changing clinician behaviour; and point-of-care tests (bedside testing) eliminate the communication breakdown problem altogether. The practice interviews highlighted transparency, and clarifying the lines of responsibility as central to improving test result communication. Enabling...
Background Given an unacceptably high incidence of diagnostic errors, we sought to identify the k... more Background Given an unacceptably high incidence of diagnostic errors, we sought to identify the key competencies that should be considered for inclusion in health professions education programs to improve the quality and safety of diagnosis in clinical practice. Methods An interprofessional group reviewed existing competency expectations for multiple health professions, and conducted a search that explored quality, safety, and competency in diagnosis. An iterative series of group discussions and concept prioritization was used to derive a final set of competencies. Results Twelve competencies were identified: Six of these are individual competencies: The first four (#1–#4) focus on acquiring the key information needed for diagnosis and formulating an appropriate, prioritized differential diagnosis; individual competency #5 is taking advantage of second opinions, decision support, and checklists; and #6 is using reflection and critical thinking to improve diagnostic performance. Thre...
Diagnostic error is increasingly recognized as a major patient safety concern. Efforts to improve... more Diagnostic error is increasingly recognized as a major patient safety concern. Efforts to improve diagnosis have largely focused on safety and quality improvement initiatives that patients, providers, and health care organizations can take to improve the diagnostic process and its outcomes. This educational policy brief presents an alternative strategy for improving diagnosis, centered on future healthcare providers, to improve the education and training of clinicians in every health care profession. The hypothesis is that we can improve diagnosis by improving education. A literature search was first conducted to understand the relationship of education and training to diagnosis and diagnostic error in different health care professions. Based on the findings from this search we present the justification for focusing on education and training, recommendations for specific content that should be incorporated to improve diagnosis, and recommendations on educational approaches that shou...
Journal of the American Society of Nephrology, 1991
The urinary sediment was examined by light microscopy in 65 consecutive inpatients with renal ins... more The urinary sediment was examined by light microscopy in 65 consecutive inpatients with renal insufficiency (not due to pre- or postrenal factors) referred to a nephrology consult service for evaluation. In the 60 patients in whom a single diagnosis was reached, the sediments of 34 (57%) contained an easily recognized cell, which we have called the "bubble cell". These cells were bizarre, large cells with a single nucleus, which appeared to contain one or more fluid-filled vesicles. Bubble cells were most prevalent in the sediment of patients with acute tubular necrosis but were also seen a variety of other renal diseases. In most patients with acute tubular necrosis, the sediment also contained "normal"-appearing renal tubular cells, muddy brown casts, and oval fat bodies which were indistinguishable from those seen in the nephrotic syndrome. By electron microscopy, the bubble cells appeared to be vacuolated renal tubular epithelial cells, which had characterist...
Objectives Improving diagnosis-related education in the health professions has great potential to... more Objectives Improving diagnosis-related education in the health professions has great potential to improve the quality and safety of diagnosis in practice. Twelve key diagnostic competencies have been delineated through a previous initiative. The objective of this project was to identify the next steps necessary for these to be incorporated broadly in education and training across the health professions. Methods We focused on medicine, nursing, and pharmacy as examples. A literature review was conducted to survey the state of diagnosis education in these fields, and a consensus group was convened to specify next steps, using formal approaches to rank suggestions. Results The literature review confirmed initial but insufficient progress towards addressing diagnosis-related education. By consensus, we identified the next steps necessary to advance diagnosis education, and five required elements relevant to every profession: 1) Developing a shared, common language for diagnosis, 2) deve...
The IOM report ‘Improving Diagnosis in Health Care’ represents a major advance in summarizing the... more The IOM report ‘Improving Diagnosis in Health Care’ represents a major advance in summarizing the problem of diagnostic error. Three new concepts in the report will be helpful in future efforts to understand and improve the diagnostic process: a new definition of diagnostic error, a new framework for understanding the diagnostic process, and a new concept of the diagnostic ‘team’. This paper highlights these new concepts and their relevance to improving diagnosis.
Crew Resource Management (CRM) training includes teamwork, communication, decision making, and th... more Crew Resource Management (CRM) training includes teamwork, communication, decision making, and the routine usage of checklists and protocols. The principles of CRM were developed in high-risk, high-reliability industries where mistakes cause disastrous consequences. In recent years, CRM practices have been introduced to hospitals to improve patient safety. This paper examines the role of debriefing in the operating room, in helping to make the surgical suite safer for patients. As one of CRM’s most powerful tools, debriefing improves communication across disciplines, provides a means for practice improvement, and assures that equipment, personnel, and technology issues are identified and addressed. Communication among professionals in the operating room and the practice of debriefing will be discussed through an examination of the experience of the anesthesia and surgical teams at Memorial Regional Hospital and Joe DiMaggio Children’s Hospital in Hollywood, Florida. It was found tha...
BackgroundErrors in reasoning are a common cause of diagnostic error. However, it is difficult to... more BackgroundErrors in reasoning are a common cause of diagnostic error. However, it is difficult to improve performance partly because providers receive little feedback on diagnostic performance. Examining means of providing consistent feedback and enabling continuous improvement may provide novel insights for diagnostic performance.MethodsWe developed a model for improving diagnostic performance through feedback using a six-step qualitative research process, including a review of existing models from within and outside of medicine, a survey, semistructured interviews with individuals working in and outside of medicine, the development of the new model, an interdisciplinary consensus meeting, and a refinement of the model.ResultsWe applied theory and knowledge from other fields to help us conceptualise learning and comparison and translate that knowledge into an applied diagnostic context. This helped us develop a model, the Diagnosis Learning Cycle, which illustrates the need for cli...
Background Communication failures involving test results contribute to issues of patient harm and... more Background Communication failures involving test results contribute to issues of patient harm and sentinel events. This article aims to synthesise review evidence, practice insights and patient perspectives addressing problems encountered in the communication of diagnostic test results. Methods The rapid review identified ten systematic reviews and four narrative reviews. Five practitioner interviews identified insights into interventions and implementation, and a citizen panel with 15 participants explored the patient viewpoint. Results The rapid review provided support for the role of technology to ensure effective communication; behavioural interventions such as audit and feedback could be effective in changing clinician behaviour; and point-of-care tests (bedside testing) eliminate the communication breakdown problem altogether. The practice interviews highlighted transparency, and clarifying the lines of responsibility as central to improving test result communication. Enabling...
Background Given an unacceptably high incidence of diagnostic errors, we sought to identify the k... more Background Given an unacceptably high incidence of diagnostic errors, we sought to identify the key competencies that should be considered for inclusion in health professions education programs to improve the quality and safety of diagnosis in clinical practice. Methods An interprofessional group reviewed existing competency expectations for multiple health professions, and conducted a search that explored quality, safety, and competency in diagnosis. An iterative series of group discussions and concept prioritization was used to derive a final set of competencies. Results Twelve competencies were identified: Six of these are individual competencies: The first four (#1–#4) focus on acquiring the key information needed for diagnosis and formulating an appropriate, prioritized differential diagnosis; individual competency #5 is taking advantage of second opinions, decision support, and checklists; and #6 is using reflection and critical thinking to improve diagnostic performance. Thre...
Diagnostic error is increasingly recognized as a major patient safety concern. Efforts to improve... more Diagnostic error is increasingly recognized as a major patient safety concern. Efforts to improve diagnosis have largely focused on safety and quality improvement initiatives that patients, providers, and health care organizations can take to improve the diagnostic process and its outcomes. This educational policy brief presents an alternative strategy for improving diagnosis, centered on future healthcare providers, to improve the education and training of clinicians in every health care profession. The hypothesis is that we can improve diagnosis by improving education. A literature search was first conducted to understand the relationship of education and training to diagnosis and diagnostic error in different health care professions. Based on the findings from this search we present the justification for focusing on education and training, recommendations for specific content that should be incorporated to improve diagnosis, and recommendations on educational approaches that shou...
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Papers by Mark Graber