Understanding diagnostic processes in emergency departments: a mixed methods case study protocol

Abstract

IntroductionDiagnostic processes in the emergency department (ED) involve multiple interactions among individuals who interface with information systems to access and record information. A better understanding of diagnostic processes is needed to mitigate errors. This paper describes a study protocol to map diagnostic processes in the ED as a foundation for developing future error mitigation strategies.Methods and analysisThis study of an adult and a paediatric academic ED uses a prospective mixed methods case study design informed by an ED-specific diagnostic decision-making model (the modified ED-National Academies of Sciences, Engineering and Medicine (NASEM) model) and two cognitive theories (dual process theory and distributed cognition). Data sources include audio recordings of patient and care team interactions, electronic health record data, observer field notes and stakeholder interviews. Multiple qualitative analysis methods will be used to explore diagnostic processes in situ, including systems information flow, human–human and human–system interactions and contextual factors influencing cognition. The study has three parts. Part 1 involves prospective field observations of patients with undifferentiated symptoms at high risk for diagnostic error, where each patient is followed throughout the entire care delivery process. Part 2 involves observing individual care team providers over a 4-hour window to capture their diagnostic workflow, team coordination and communication across multiple patients. Part 3 uses interviews with key stakeholders to understand different perspectives on the diagnostic process, as well as perceived strengths and vulnerabilities, in order to enrich the ED-NASEM diagnostic model.Ethics and disseminationThe University of Michigan Institutional Review Board approved this study, HUM00156261. This foundational work will help identify strengths and vulnerabilities in diagnostic processes. Further, it will inform the future development and testing of patient, provider and systems-level interventions for mitigating error and improving patient safety in these and other EDs. The work will be disseminated through journal publications and presentations at national and international meetings.

Designing Patient-Centered Interventions for Emergency Care: Participatory Design Study with Patients (Preprint)

“…A presentation of the ED care process timeline (See Figure 2) was shown to prompt participants to recall their previous or most recent ED experience. We created this timeline based on our last interview study [15] and prior work on the ED care framework [16]. We first asked participants to write down one major challenge from this experience and expressly point out where this occurred in the current ED care process timeline in their packet.…”

Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis

“…Neither the reasoning of clinicians nor the ED systems and processes, particularly tasks and communications, during the acute stroke diagnostic process have been well characterized 1,10 . Retrospective chart reviews and malpractice claims data have primarily been used to understand the ED diagnostic processes for acute stroke 11,12 .…”

“…Neither the reasoning of clinicians nor the ED systems and processes, particularly tasks and communications, during the acute stroke diagnostic process have been well characterized. 1,10 Retrospective chart reviews and malpractice claims data have primarily been used to understand the ED diagnostic processes for acute stroke. 11,12 A failure modes, effects, and criticality analysis (FMECA), an engineering method, used initially in high-risk industries such as aerospace and nuclear power, but increasingly applied to health care, involves engaging stakeholders to describe the steps and workflows of a process and to identify the vulnerabilities or failures of each step and then to characterize their underlying causes, frequency, potential harm to the patient, and any existing safeguard(s) to mitigate or eliminate, using standardized scores.…”