Understanding diagnosis through ACTion: evaluation of a point-of-care checklist for junior emergency medical residents

Abstract

Background Avoiding or correcting a diagnostic error first requires identification of an error and perhaps deciding to revise a diagnosis, but little is known about the factors that lead to revision. Three aspects of reflective practice, seeking Alternative explanations, exploring the Consequences of missing these alternative diagnoses, identifying Traits that may contradict the provisional diagnosis, were incorporated into a three-point diagnostic checklist (abbreviated to ACT). Methods Seventeen first and second year emergency medicine residents from the University of Toronto participated. Participants read up to eight case vignettes and completed the ACT diagnostic checklist. Provisional and final diagnoses and all responses for alternatives, consequences, and traits were individually scored as correct or incorrect. Additionally, each consequence was scored on a severity scale from 0 (not severe) to 3 (very severe). Average scores for alternatives, consequences, and traits and the severity rating for each consequence were entered into a binary logistic regression analysis with the outcome of revised or retained provisional diagnosis. Results Only 13% of diagnoses were revised. The binary logistic regression revealed that three scores derived from the ACT tool responses were associated with the decision to revise: severity rating of the consequence for missing the provisional diagnosis, the percent correct for identifying consequences, and the percent correct for identifying traits (χ2 = 23.5, df = 6, p < 0.001). The other three factors were not significant predictors. Conclusions Decisions to revise diagnoses may be cued by the detection of contradictory evidence. Education interventions may be more effective at reducing diagnostic error by targeting the ability to detect contradictory information within patient cases.

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

“…Sibbald’s cardiac exam checklist reported 51% accuracy with checklist use vs 46% diagnostic accuracy without (p=0.04)52; and Shimizu’s symptom-specific checklists reported 67% diagnostic accuracy with the checklist vs 60% without (p<0.05) 57. One study (Kilian’s ACT mnemonic) reported no significant improvements in postchecklist diagnostic accuracy 62…”

“… 57 One study (Kilian’s ACT mnemonic) reported no significant improvements in postchecklist diagnostic accuracy. 62 …”

“…Four of these studies (two pretest and post-test studies,46 47 one survey-based study48 and one study with a focus-group design)21 obtained user feedback when using a checklist. The remaining fourteen, including five pretest and post-test studies,51 52 57 62 63 six randomised controlled trials (RCTs),22 40 55 61 64 65 two quasi-experimental studies44 66 and one retrospective cohort study,56 evaluated whether checklists reduced diagnostic error. The main outcomes reported within those 14 studies included diagnostic accuracy, number of errors, number of abnormalities found on imaging and patient outcomes such as length of stay (tables 2 and 3).…”

“…Within the 14 studies testing checklists, most checklists targeted the Cognitive subcomponent (n=10)22 40 44 55–57 61 62 65 66 followed by Tasks (n=7)22 51 52 57 63–65 (table 3). Two studies targeted the Internal Environment and the Professional Outcomes subcomponents 44 66.…”

Accuracy and usability of a diagnostic decision support system in the diagnosis of three representative rheumatic diseases: a randomized controlled trial among medical students

“…The majority of mistakes in the diagnosis are caused by cognitive errors [ 6 ], and besides educational strategies, checklists have successfully been implemented in medicine to reduce errors and increase treatment quality [ 7 ], e.g., reducing central line infection rates [ 8 ] and surgical complications [ 9 ]. Diagnostic decision support systems (DDSS) and symptom checkers (SCs) are increasingly used [ 10 – 12 ] and promise to help patients and healthcare professionals to establish the correct diagnosis by providing a checklist of differential diagnoses [ 13 ].…”