Integrating strategies for improving diagnostic reasoning and error reduction

Abstract

Errors of diagnostic reasoning contribute significantly to patient harm. Students, novice diagnosticians, and even experienced clinicians often have difficulty understanding or describing the processes of diagnostic reasoning. Inappropriate use of cognitive heuristics and poor logical reasoning by novice or experienced diagnosticians may result in missed or delayed diagnoses. Reduction of diagnostic errors through knowledge acquisition, self-reflection, and check lists has individually demonstrated some improvements in diagnostic reasoning. Implementing the diagnostic and reasoning tool (DaRT), a method of reasoning which integrates the evidence-based strategies of knowledge acquisition, metacognition, and logical reasoning skills throughout the patient encounter, results in improvement in diagnostic reasoning in advanced practice nurses. Use of the DaRT in one university setting resulted in significant improvement in advanced health assessment skills and diagnostic reasoning abilities as demonstrated by improvements of 28–55% end-of-program Health Education Systems Incorporated scores. Translation into practice settings may further support the use of this multiple-modality tool.

Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework

“…Fifteen out of the 25 checklists addressed Work Systems 20 22 42–53. Two of those checklists addressed the Persons subcomponent,45 46 13 addressed Tasks,20 22 42 43 45 47–53 and 3 addressed Internal Environment (table 1). 44–46 Notably, no checklists focused on Tools and Technologies, or External Environment.…”

“…Six checklists emphasised broadening the history, physical exam or tests to aid in the diagnostic process 20 22 49 53 56 58. For example, Nordick’s Diagnostic and Reasoning Tool checklist contained an annotated flow chart that walks providers through ‘chief complaint,’ ‘history of present illness’ and ‘physical exam’ while providing broad diagnostic questions to consider while performing these steps 49.…”

“…Six checklists emphasised broadening the history, physical exam or tests to aid in the diagnostic process 20 22 49 53 56 58. For example, Nordick’s Diagnostic and Reasoning Tool checklist contained an annotated flow chart that walks providers through ‘chief complaint,’ ‘history of present illness’ and ‘physical exam’ while providing broad diagnostic questions to consider while performing these steps 49. Similarly, Weber’s checklist for orbital or periorbital cellulitis outlined specific points in the history and physical (eg, ‘onset’ ‘catastrophic (hours))’ and followed by diagnoses in order of likelihood 58…”

Scoping review: Diagnostic reasoning as a component of clinical reasoning in the U.S. primary care nurse practitioner education

“…In the domain of clinical reasoning for the healthcare clinical practice professions, diagnostic reasoning (DR) has been identified as an essential cognitive competency for safe and effective practice (Graber et al, 2018 ; IOM, 2015 ). DR can be defined as that component of clinical reasoning that focuses on getting to the clinical diagnoses and determining relevant management of the clinical problems (Nordick, 2021 ; Rajkomar & Dhaliwal, 2011 ). Effective DR has been linked to improved quality of care and care outcomes (Graber et al, 2018 ; IOM, 2015 ), and is necessary for clinical problem definition, reducing diagnostic error and determining appropriate management.…”

“…DR, a subset of clinical reasoning, is the cognitive process used to collect and interpret data to medically diagnose and treat patients (Nordick, 2021 ; Rajkomar & Dhaliwal, 2011 ). Whilst medicine sometimes uses the term clinical reasoning interchangeably with DR, in nursing practice the term clinical reasoning has a broader meaning, referring both to RN practice and decision making as well as to NP practice.…”