The pursuit of better diagnostic performance: a human factors perspective

by:INDUSTRIAL-MAN     2019-09-16
Although the start of treating diagnostic errors as an easy-to-accept research topic is relatively slow at the beginning of patient safety exercise, interest in research has steadily increased over the past few years, meetings are held on a regular basis, expanding literary works and even a new professional society.
However, it is increasingly recognized that improving diagnostic performance is a multifaceted challenge.
From the perspective of human factors, this paper discusses some of these challenges, including focusing on who owns the problem, treating cognitive and systemic deficiencies as separate questions, and why there is not enough knowledge in the mind, what do we learn from health information technology (IT)
And the use of the checklist.
In order to encourage empirical testing of interventions aimed at improving diagnostic performance, a rapid-
Loop prototype and simulation are proposed.
In order to have a more comprehensive understanding of the complexity of the socio-technical space for conducting diagnostic work, the final note requires a substantive partnership with people in disciplines other than the clinical field.
A few years ago, a question was raised as to why diagnostic errors did not receive much attention compared to other adverse events that gave greater safety attention to patients.
Most of the negligence can be traced back to the Institute of Medicine (IOM)
The human report is wrong.
The overall view of the report is
Family information is that preventable adverse events are caused by a complex set of systemic factors, not by mistakes by individual clinicians.
The report immediately had an impact on the media.
For a long time, many health care leaders have realized that their careers are scattered and they have accepted a system --
Methods for patient safety.
Focus on identifiable system failures-medication mix-
Communication Mistakes and mistakes-site surgeries—
A diagnostic error appears to be left in the shadow.
However, two systems were involved in the diagnostic error
Related and individual components and many other factors.
However, the relevant researchers quickly drew attention to diagnostic errors, raised awareness of diagnostic errors, and conducted studies.
3-6 funding agencies and foundations have been notified.
Health Care Research and Quality institutions in the past 7 years (AHRQ)
In the United States, some diagnostic error meetings have been supported and a Notice of Special emphasis has been posted on its website requesting a study of diagnostic performance in an outpatient care setting.
In order to further raise awareness, research and education, thought leaders in emerging disciplines have launched a new professional society-Medical Association for the Advancement of diagnosis.
It is undeniable that diagnostic errors are respected and recognized as an area worthy of research.
However, challenges remain despite the high enthusiasm.
Two recent literary reviewsone on system-
Related and other interventions of cognitive intervention
It was found that there was a big gap between the suggestions and ideas for interventions and those that had been implemented and tested with experience.
In order to have a lasting impact on the safety of patients, it is necessary to face these challenges frankly and conduct a critical examination of them.
Whose is the problem?
As many doctors think
Based on the fact that failure is a systemic problem, healthcare CEOs and managers also see diagnostic errors as something for individual physicians.
Both views are very short. sighted.
They did not take into account the interaction and dependence between imperfect people and their imperfect working environment.
Each part of the diagnostic error equation is cut to another part, which hinders meaningful communication and cooperation.
There are both problems.
As purchasing officers and system administrators, physicians need to pay equal attention to the lack of interoperable health IT systems, increase the complexity of workflows, and introduce usability issues that threaten patient safety.
Similarly, managers and unit directors should also pay equal attention to the host of cognitive restrictions and the working conditions that promote restrictions such as clinicians themselves.
In the absence of meaningful dialogue and a sense of shared ownership, it is not surprising if \"we are doing well here\" is a mindset.
When the knowledge in the mind is not enough, the difference between the knowledge in the mind and the knowledge in the world is made by Donald Norman a few years ago.
As a cognitive psychologist, Norman certainly appreciates the known information processing and storage capabilities of human beings, but the knowledge in the mind is not always searchable when needed.
When it comes to considering the various possibilities that can be used to make the best diagnosis, the whole range is not considered.
Using the terms introduced by Simon10 to predate the term \"premature closure\" we currently use, we \"satisfy\" by spending the least amount of cognitive effort and accepting the first seemingly satisfying possibility \".
Norman believes that by putting more knowledge in the world, rather than relying solely on the knowledge in our minds, our daily and professional lives will become easier and less error-free.
Many process errors related to diagnostic surveys can be reduced by visual and accessible information display and tracking systems
Appointment of patient referral, test results and follow-upup actions.
The main author recently received a solicitation from a nearby community hospital to donate an electronic whiteboard (census board)
A tracking system for their emergency department.
While Dangdang hospital recognizes the lack of head knowledge in today\'s message, this is an encouraging sign --
Intensive clinical environment, shift from drying
Erasing boards to electronic boards does not always take into account the distribution and social nature of clinical work.
If disconnected from regular workflow patterns and provider requirements, the usefulness of electronic boards may be limited.
As with other clinical work, 11, 12 diagnostic work is embedded in a larger social technology system.
Rather than limiting our view that improved diagnostic performance means more knowledge in the mind, or just what happens when a doctor meets a patient, a more inclusive view is that, diagnostic work is distributed across time and place --
Distributed cognition, 13 shared mental models 14 and joint cognitive system 15 are several related terms used
And constantly influenced by the direct and indirect interaction between suppliers, experts, technicians, patients, test results, artifacts, tools, technologies, organizational structures and cultures, and local environmental factors, and changing health policies and emotions.
In short, diagnostic work often involves more than just the revelation of \"between ears.
For patients, family members, and clinicians, this can be a disjointed journey through chaotic terrain, helped or hindered by different agents, unable to see the destination, with few landmarks along the way.
Is apartheid a good thing?
In many emerging literature and conferences to date, cognitive problems and biases (
Including perception and emotional bias)
System failures are generally treated as separate entities.
This division is caused by a key problem that investigators seem to face.
Is there a better effort to improve diagnostic performance to correct tendencies towards cognitive and emotional bias (
Premature closure, overconfident and visceral bias17)
And other cognitive skits.
Or can it be easier to improve diagnostic performance through system solutions, such as decision support systems that circumvent concerns about cognitive bias?
Both camps have their own supporters, and both methods are under-recorded.
Convincing demonstrations of effective cognitive bias techniques are rare and troublesome --
Poorly integrated support systems with clinical workflow were not adopted by busy physicians.
Explaining the problem in this way will encourage unnecessary camp choices.
While camp life may offer its members a feeling of easy agreement and solidarity, there are also some shortcomings for those who become too comfortable in the camp.
The downside could be distrust of outsiders with different views, disregard for messages that do not conform to universal beliefs, and a lot of self-
Reference endorsement.
Overall, these are not the best qualities to understand the complexity of the system.
However, humans with limited cognitive ability can also show extraordinary adaptability in reality --
Life Decision 20, 21 and faulty systems gradually become better in terms of functionality, interoperation and usefulness.
Neither will disappear: The Advantages and limitations of the two interact inseparably and will continue to affect the diagnostic process.
When one considers the diagnostic work of the busy emergency department and its chaotic system combination, the hypothetical distinction between \"cognition\" and \"system\" becomes somewhat false
Patient factors based on cognition, emotion, perception, time and variability.
Of course, both cognitive and systemic variables can be operated and tested separately, but both types of variables interact in a clinical setting, the interaction terms in our analysis should be as interesting as the main effects.
In fact, in more than one
Field surveys by primary care physicians on diagnostic challenges, when respondents were specifically asked about the role of cognitive factors, they also referred to both system and patient factors.
The danger of too eager to embrace the second will always exist --
For those who are learned, it is no less than those who have no one.
Of course, they may initially be useful novels or labels that help simplify complex phenomena.
But the dichotomy tends to assert too much, and when their excessive use hinders the illusion of understanding, they fuel the illusion of understanding.
Not as a convenient short-term service
They accept, without criticism, the explanatory power as a cause rather than a consequence.
Analyze the world as imperfect human beings and imperfect systems
Based on the research method, enter System 1 (intuitive)
With System 2 (analytical)
The 23, 24-year-old mindset missed most of the human factors previously cited for shared mental models and distributed cognition.
What have we learned from health?
The utilization and potential benefits of electronic health records in helping to improve diagnostic performance have been properly noted.
25 Some of these possibilities include providing an understanding of the patient\'s changing medical history;
Provide a forwarding
Record the mobile space for patient and clinician evaluation, attention and uncertainty;
Supports continuous updating and rearranging of problem lists;
Provide tips to help ask key questions that should not depend on memory;
Track test order, results, and tracking
With patients.
And provide feedback on results because doctors and organizations lack a systematic mechanism to learn and calibrate performance from diagnostic work.
But the potential benefits are not the same as the actual ones.
A recent report by the International Organization for Migration on Health states that its adoption and widespread use in the United States is slow.
27 at the same time, there is concern that if designed and implemented improperly, health can create new dangers and threaten patient safety in a healthcare environment already known for its complexity and fragmentation.
Of all hazard categories identified in government reports reviewing health IT hazards, software design and availability issues (
For example, information acquisition is difficult, data input is difficult, information display is chaotic, memory requirements are too high, and feedback to users is chaotic)
Most mentioned (
52% and 49%, respectively).
28 when users interact with them in an unfriendly and ruthless working environment, the dangers that inadvertently exist in our most advanced and promising technologies deserve continued attention.
Healthcare organizations, suppliers and researchers need to work together on design, availability and implementation issues in the spirit of learning communities.
Suppliers need to be involved in the early stages of the design.
As the beginning of this direction, the Department of Veterans Affairs of the United States has established an availability laboratory to support rapid prototyping of new health IT designs, formal usability testing and development of analytical tools to evaluate existing technologies.
29 The results of the risk assessment used to determine the consequences of a health accident need to be fed back to the supplier.
Similarly, suppliers may need encouragement and assistance in conducting their own usability tests and risk assessments, as well as understanding the broader social technology security consequences of their products.
In addition to the accessibility and availability issues that the human factor community has long focused on, the bigger challenge of using health IT is how to better educate and empower patients to see themselves as active partners in their medical history, diagnostic work
Ups and improved care.
Does the list work?
Although the list has been used in other hazardous industries for decades, due to the successful reduction of blood flow infections in intensive care units, reduced surgical morbidity and mortality in different global settings, it has entered the re-
Design the discharge process to reduce avoidable re-admission.
31-35 recently, a number of papers have emerged calling for further exploration of their application in diagnostic work.
36, 37 in order to reduce undue reliance on memory and heuristics and to help curb over-self-confidence, the diagnostic list suggests ranging from general steps that residents are familiar with but are often overlooked by busy practitioners, for a more comprehensive list of differences and those with more critical possibilities that should be considered and discounted before making a final diagnosis.
The development, use and acceptance of the checklist are all challenged.
Development requires an individual team or consensus body that is good at the best practice guidelines and the underlying evidence base, in the realistic, measured and human factor design principles of clinical work, and has the perseverance to engage in continuous pilot-
Test and improve.
If put together too quickly, the checklist may be too lengthy, ambiguous, lacking clinical reality and not sensitive to the needs of the front lineline users.
Even if it is finally well developed and accepted
User, repetition itself seems to lead to cognitive drift.
The task of repeating and becoming regular is performed with nominal cognitive resources.
If clinicians \"adjust\" and use checklists in a perfunctory manner, they may miss subtle and unexpected hints about the patient\'s condition.
The list is mainly based on past failures, and reluctant persistence cannot replace high sensitivity to other ways of process failure (
Of course, once the horse runs away, \"close the barn door\" will appear on the list, but the owner checks the loose side --
Do planes at horse stands? ).
Finally, the investigators who successfully implemented the checklist quickly told us that this was not entirely a problem with the checklist.
A popular culture of patient safety, teamwork, leadership commitment
Prior to the proper testing of the inventory, the measurements of the conception and the focus on implementation, workflow, and organizational change issues need to be carefully aligned.
So far, the list has been the most successful for discrete, observable tasks --
Patients associated with surgery, central venous catheter, and discharge procedures.
At the same time, a certain amount of diagnostic process involves individual psychological activities --
Perception, thinking and interpretation
This is not very obvious.
Are there any obvious beginnings of these mental activities? and stop-
Can you use the points of the checklist?
Other diagnostic studies are characterized as \"evil problems\" 16, 38, where there is no clear final goal or path, there is no credible test progress, and decisions made can lead to new uncertainties, it is difficult to evaluate and compare tentative solutions with known and unknown effects.
Obviously, a better understanding of the effective use and limitations of checklists in diagnostic work is needed.
Engineering strategies for improving evidence base hospitals and primary health care offices are often fluid and dynamic places where interruptions, scheduling mistakes and unexpected situations are commonplace.
While dynamic environments may be ideal for research objectives promoted by observation or ethnographic methods, they are not ideal for testing the effects of the intervention and safely attribute the results to independent variables of interest, the results were also affected by background and organizational variables that investigators could barely control.
However, it is necessary to conduct prospective empirical testing of methods designed to improve diagnostic performance.
Simulation and system engineering methods are being used as a test
Bed for healthy IT and medical equipment.
39-41 there is a strategy that is fast
A circular prototype design is carried out in a simulated environment to test the various promising functions of the intervention design.
After evaluating the results, improving the prototype and testing again, the test-evaluation-improvement cycle will continue until satisfied with the validity of the prototype (
Or discard if you are not satisfied).
Early failure, late failure
In the later stages of development, a large amount of resources are occupied)
Is the true word of engineering.
There are many diagnostic challenges that do not require an actual clinical setting or even a high
Simulate the environment, but only need to achieve the necessary functional fidelity;
That is to say, diagnostic experts or teams are required to deal with the same clues, the same variable condition, the same incomplete information and uncertainty while being subject to the same constraints and time pressures, make the same decision, take the same action and be informed of the same consequences as the clinical situation.
42,43 through iterative testing-evaluation-improvement process in a simulated environment, researchers are more likely to resist temptation and seek immediate scientific satisfaction in comparing premature interventions with resource control groups --
Intensive clinical setting and ambiguous results are presented.
44 however, once satisfied with the effectiveness of the intervention, it is still necessary to test the effectiveness of the intervention in the use environment --
Noise, time pressure, and interrupted \"flesh and blood\" clinical environment.
Similar improvements may be needed at work
The system and context factors that need to be aligned are determined.
The last of many constructive comments published by the paper reviewer is a suitable break-up message.
It was observed that most of the funded research and published works on improving diagnosis came from clinicians.
Why not engage with experts in human performance, perception, cognition and decision-making is the question raised.
There are exceptions, but they are still exceptions.
In other areas of patient safety, clinicians and human factors professionals have joined forces to form an integrated team to advance this area.
Emerging disciplines for diagnostic improvement require the sound of human factors --
Not just a voice, but a few, not just the voice of the people who live in the camp.
Orthodox ideas in security research are not good for anyone.
45 to gain a fuller understanding of the interactivity and complexity of the social technology space in which diagnostic work is performed, clinicians and their human factors peers, as well as other disciplines, have the opportunity to build substantial partnerships for long-term developmentWork early in the semester.
Until we learn to do so, progress may be less than expected.
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