Summary: Diagnostic Errors And Root Cause Analysis

Diagnostic Errors and Root Cause Analysis
September 25, 2013

Table of Contents
Introduction……………………………………………………………………3
Background…………………………………………………………………….3
Errors Identification…………………………………………………………....3
Cognitive Skills…………………………………………….4
Quality Measures......................................................................................................5
Patient-Centered Care……………………………………...6
Teamwork and Collaboration………………………………6
Evidence-Based Practice…………………………………...7
Continuous Quality Improvement……………………….....7
Safety……………………………………………………….8
Informatics………………………………………………….8
Strategies for Diagnostic Error Prevention and Barriers to Error Prevention…..8
Conclusion………………………………………………………………………9
Cognitive skill errors may lead to the ignorance of patient 's needs and rights. Considering patient and family members as part of the treatment plan is necessary because they know how they are doing better than anyone else. For example, when Helen expresses her concern of Lewis’ pain, nurse told Helen that the pain is gas and Lewis needs to move around although Lewis is having slight fever, cold to touch, and pain is five on scale of five (Helen Haskell, 2009). This premature closure has led to fail to treat Lewis properly. Another example is when Helen calls nurse many times to complain about Lewis’ pain, she tries to convince Helen that Lewis is not walking enough to relief the gas (Helen Haskell, 2009).Availability bias and responsiveness bias may also affect nurse 's belief on the cause of pain and lead to wrong diagnosis. Nurse may have seen many patients who have gas pain prior to Lewis and they use their past experience of gas pain to diagnose Lewis’ problem without considering other possibilities. The nurse also seeks data relevant with gas pain while she ignores the data relate to internal bleeding. The other failure of patient-center care in Lewis story is no one notices the deadly side effect of Ketorolac although it is stated clearly about the
Premature closure may harm patient and put patient at risk for injuries as diagnostic errors occur. Doctor will make incorrect diagnosis if the data is not fully collected and lead to delayed or wrong treatment. This put patient at risk for injuries potentially.Health care providers havefailed to provide safety care for Lewis. In Lewis ' case, Lewis ' belly is distended and hard, temperature drops, eyes are sunken, skin grows pale, and experience great pain (Helen Haskell, 2009). These are signs and symptoms of possible intestinal perforation and internal leakage instead of blocked intestine and the resident and nurse should assume the worst and gather more data either to rule it in or out. Nurse who took care of Lewis has failed to assess Lewis and jumped to conclusion that Lewis is not walking enough to relief gas pain. The resident should order computed tomography scan to rule out intestinal bleeding and confirm his diagnosis.If the nurse, residents, and veteran doctor communicate with each other, Lewis’ problem will not get worse and worse instead Lewis might be