- Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care. Balogh EP, Miller BT, Ball JR, eds. Washington, DC: National Academies Press; 2015. https://www.ncbi.nlm.nih.gov/ books/NBK338596/. Accessed September 2, 2022.
- Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving U.S. adult populations. BMJ Qual Saf. Sep 2014;23(9):727-731. doi:10.1136/bmjqs-2013-002627. Accessed September 2, 2022.
- Agency for Healthcare Research and Quality. Diagnostic Safety and Quality. Accessed September 2, 2022.
- Graber ML, Rusz D, Jones ML, Farm-Franks D, Jones B, Cyr Gluck J, Thomas DB, Gleason KT, Welte K, Abfalter J, Dotseth M, Westerhaus K, Smathers J, Adams G, Laposata M, Nabatchi T, Compton M, Eichbaum Q. The new diagnostic team. Diagnosis (Berl). 2017;4(4):225-238. doi:10.1515/dx-2017-0022. Accessed September 2, 2022.
- Graber ML, Grice GR, Ling LJ, Conway JM, Olson A. Pharmacy education needs to address diagnostic safety. Am J Pharm Educ. 2019;83(6):7442. doi:10.5688/ajpe7442. Accessed September 2, 2022.
- Gleason K, Harkless G, Stanley J, Olson APJ, Graber ML. The critical need for nursing education to address the diagnostic process. Nurs Outlook. 2021;69(3):362-369. doi:10.1016/j.outlook.2020.12.005. Accessed September 2, 2022.
- Olson A, Rencic J, Cosby K, Rusz D, Papa F, Croskerry P, Zierler B, Harkless G, Giuliano MA, Schoenbaum S, Colford C, Cahill M, Gerstner L, Grice GR, Graber ML. Competencies for improving diagnosis: an interprofessional framework for education and training in health care. Diagnosis (Berl). 2019;6(4):335-341. doi:10.1515/dx-2018-0107. Accessed September 2, 2022.
- Olson APJ, Danielson J, Stanley J, Graber ML. Improving Education—A Key to Better Diagnostic Outcomes. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0026-1-EF. Accessed September 2, 2022.
- Cahill M, Gleason K, Harkless G, Stanley J, Graber M. The regulatory implications of engaging registered nurses in diagnoses. J Nurs Regul. 2019;10(2):5-10. doi:10.1016/S2155-8256(19)30110-3. Accessed September 2, 2022.
- Gleason KT, Davidson PM, Tanner EK, Baptiste D, Rushton C, Day J, Sawyer M, Baker D, Paine L, Himmelfarb CRD, Newman-Toker DE. Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. Diagnosis (Berl). 2017;4(4):201-210. doi:10.1515/dx-2017-0015. Accessed September 2, 2022.
- Considine J. Nurses, diagnosis, and diagnostic error. Diagnosis. 2017;4(4):197-199. doi:10.1515/dx-2017-0027. Accessed September 2, 2022.
- Zwaan L, El-Kareh R, Meyer AND, Hooftman J, Singh H. Advancing diagnostic safety research: results of a systematic research priority setting exercise. J Gen Intern Med. 2021;36(10):2943-2951. doi:10.1007/s11606-020-06428-3. Accessed September 2, 2022.
- Graber ML, Rencic J, Rusz D, Papa F, Croskerry P, Zierler B, Harkless G, Giuliano M, Schoenbaum S, Colford C, Cahill M, Olson APJ. Improving diagnosis by improving education: a policy brief on education in healthcare professions. Diagnosis (Berl). 2018;5(3):107-118. doi:10.1515/dx-2018-0033. Accessed September 2, 2022.
- Carr S. Supporting Nurses as Essential Partners in Diagnosis. ImproveDx Newsletter. 2021 Mar;8. Accessed September 2, 2022.
- Gleason KT, Greenberg P, Dennison Himmelfarb CR. Nurses are key in preventing deadly diagnostic errors in cardiovascular diseases. J Cardiovasc Nurs. 2019;34(1):6-8. doi:10.1097/jcn.0000000000000542. Accessed September 2, 2022.
- Gleason KT, Jones R, Rhodes C, Greenberg P, Harkless G, Goeschel C, Cahill M, Graber M. Evidence that nurses need to participate in diagnosis: lessons from malpractice claims. J Patient Saf. 2021;17(8):e959-e963. doi:10.1097/pts.0000000000000621. Accessed September 2, 2022.
- Rosen M, Ali KJ, Buckley BO, Goeschel C. Leadership To Improve Diagnosis: A Call to Action. Rockville, MD: Agency for Healthcare Research and Quality; June 2021. AHRQ Publication No. 20(21)-040-5-EF. https://www.ahrq.gov/patient-safety/reports/issue-briefs/leadership.html. Accessed September 2, 2022.
- McCloskey Dochterman J, Bulechek G. Surveillance safety. In: McCloskey Dochterman J, Bulechek G, eds. Nursing Interventions Classification. 4th ed. St. Louis, MO: Mosby; 2004.
- Henneman EA, Gawlinski A, Giuliano KK. Surveillance: a strategy for improving patient safety in acute and critical care units. Crit Care Nurse. 2012;32(2):e9-e18. doi:10.4037/ccn2012166. Accessed September 2, 2022.
- Dresser S. The role of nursing surveillance in keeping patients safe. J Nurs Adm. 2012;42(7/8):361-368. doi:10.1097/NNA.0b013e3182619377. Accessed September 2, 2022.
- Halverson CC, Scott Tilley D. Nursing surveillance: a concept analysis. Nurs Forum. 2022;57(3):454-460. doi:10.1111/nuf.12702. Accessed September 2, 2022.
- Pfrimmer DM, Johnson MR, Guthmiller ML, Lehman JL, Ernste VK, Rhudy LM. Surveillance: a nursing intervention for improving patient safety in critical care environment. Dimens Crit Care Nurs. 2017;36(1):45-52. doi:10.1097/dcc.0000000000000217. Accessed September 2, 2022.
- Kutney-Lee A, Lake ET, Aiken LH. Development of the hospital nurse surveillance capacity profile. Res Nurs Health. 2009;32(2):217-228. doi:10.1002/nur.20316. Accessed September 2, 2022.
- Thomas DB, Newman-Toker DE. Diagnosis is a team sport - partnering with allied health professionals to reduce diagnostic errors. Diagnosis (Berl). 2016;3(2):49-59. doi:10.1515/dx-2016-0009. Accessed September 2, 2022.
- Society to Improve Diagnosis in Medicine. Clinician Checklists. Accessed September 2, 2022.
- Singh H. Diagnostic error: safe and effective communication to prevent diagnostic errors. Middleton, MA: Patient Safety & Quality Healthcare; June 3, 2013. Accessed September 2, 2022.
- De Meester K, Verspuy M, Monsieurs KG, Van Bogaert P. SBAR improves nurse-physician communication and reduces unexpected death: a pre and post intervention study. Resuscitation. 2013;84(9):1192-1196. doi:10.1016/j.resuscitation.2013.03.016. Accessed September 2, 2022.
- Müller M, Jürgens J, Redaèlli M, Klingberg K, Hautz WE, Stock S. Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open. 2018;8(8):e022202. doi:10.1136/bmjopen-2018-022202. Accessed September 2, 2022.
- Murphy DR, Singh H, Berlin L. Communication breakdowns and diagnostic errors: a radiology perspective. Diagnosis (Berl). 2014;1(4):253-261. doi:10.1515/dx-2014-0035. Accessed September 2, 2022.
- Shahid S, Thomas S. Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care – a narrative review. Saf Health. 2018;4(7). doi:10.1186/s40886-018-0073-1. Accessed September 2, 2022.
- Agency for Healthcare Research and Quality. TeamSTEPPS® for Diagnosis Improvement. Last reviewed March 2022. Accessed September 2, 2022.
- Davis K, Collier S, Situ J, Coe M, Cleary-Fishman M. A Toolkit To Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. https://www.ahrq.gov/hai/tools/ambulatory-care/safe-transitions.html. Accessed September 2, 2022.
- Agency for Healthcare Research and Quality. Be The Expert On You. Last reviewed July 2022. https://www.ahrq.gov/patient-safety/settings/ambulatory/tools/diagnostic-safety/toolkit.html. Accessed September 2, 2022.
- Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. Med Educ Online. 2011;16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3081249/. Accessed September 2, 2022.
- Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: 2016 Update. Washington, DC: Interprofessional Education Collaborative; 2016. https://ipec.memberclicks.net/assets/2016-Update.pdf. Accessed September 2, 2022.
- Institute of Medicine Committee on the Health Professions Education Summit. Health Professions Education: A Bridge to Quality. Greiner AC, Knebel E, eds. Washington, DC: National Academies Press; 2003. https://www.ncbi.nlm.nih.gov/books/NBK221528/. Accessed September 2, 2022.
- American Association of Colleges of Nursing. The Essentials: Core Competencies for Professional Nursing Education. 2021. https://www.aacnnursing.org/AACN-Essentials. Accessed September 2, 2022.
- Agency for Healthcare Research and Quality. Teamwork Perceptions Questionnaire (T-TPQ). Last reviewed April 2017. https://www.ahrq.gov/teamstepps/instructor/reference/teampercept.html. Accessed September 2, 2022.
- TeamSTEPPS® Team Assesment Tool for Improving Diagnosis - Instructions. Rockville, MD: Agency for Healthcare Research and Quality; February 2022. AHRQ Publication No. 22-0015. https://www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/dxsafety-team-assessment-tool.pdf. Accessed September 2, 2022.
- Vaona A, Banzi R, Kwag KH, Rigon G, Cereda D, Pecoraro V, Tramacere I, Moja L. E-learning for health professionals. Cochrane Database Syst Rev. 2018;1(1):Cd011736. doi:10.1002/14651858.CD011736.pub2. Accessed September 2, 2022.
- Giardina TD, Haskell H, Menon S, Hallisy J, Southwick FS, Sarkar U, Royse KE, Singh H.. Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety. Health Aff (Millwood). 2018;37(11):1821-1827. doi:10.1377/hlthaff.2018.0698. Accessed September 2, 2022.
- Cohen DL, Stewart KO. The stories clinicians tell: achieving high reliability and improving patient safety. Perm J. 2016;20(1):85-90. doi:10.7812/tpp/15-039. Accessed September 2, 2022.
- Shah RK, Godambe SA, eds. Patient Safety and Quality Improvement in Healthcare: A Case-Based Approach. New York, NY: Springer Nature; 2020.
- McLean SF. Case-based learning and its application in medical and health-care fields: a review of worldwide literature. J Med Educ Curric Dev. 2016 Apr 27;3:JMECD.S20377. doi:10.4137/jmecd.S20377. Accessed September 2, 2022.
- Allchin D. Problem- and case-based learning in science: an introduction to distinctions, values, and outcomes. CBE Life Sci Educ. 2013;12(3):364-372. doi:10.1187/cbe.12-11-0190. Accessed September 2, 2022.
- Thistlethwaite JE, Davies D, Ekeocha S, Kidd JM, MacDougall C, Matthews P, Purkis J, Clay D. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach. 2012;34(6):e421-e44. doi:10.3109/0142159x.2012.680939. Accessed September 2, 2022.
- Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer DB. Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiol Clin. 2007;25(2):361-76. doi:10.1016/j.anclin.2007.03.007. Accessed September 2, 2022.
- Society to Improve Diagnosis in Medicine. Patient Stories. https://www.improvediagnosis.org/stories/. Accessed September 2, 2022.
- The Patient Safety Network [PSNet]. WebM&M: Case Studies. https://psnet.ahrq.gov/webmm-case-studies?f%5B0%5D=webmm_safety_target%3A4784. Accessed September 2, 2022.
- Agency for Healthcare Research and Quality. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events. July 2022. AHRQ Publication No. 22-0038. https://www.ahrq.gov/patient-safety/settings/measure-dx.html. Accessed August 5, 2022.
- Dreifuerst KT. Getting started with debriefing for meaningful learning. Clin Simul Nurs. 2015;11(5):268-275. doi:10.1016/j.ecns.2015.01.005. Accessed September 2, 2022.
- Society to Improve Diagnosis in Medicine. Competencies & Learning Objectives: Consensus Curriculum on Diagnosis. https://www.improvediagnosis.org/consensuscurriculum-competencies/. Accessed September 2, 2022.
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Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators
References
Table of Contents
- Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators
- Introduction
- Nurses’ Roles in the Diagnostic Process
- Recognizing and Supporting Nurses in Diagnostic Safety
- Using Patient Cases for Learning
- Conclusion
- References
- Appendix A. SIDM Competencies To Improve Diagnosis and Suggested Questions for Debriefing Case Studies
Page last reviewed September 2022
Page originally created September 2022
Internet Citation: References. Content last reviewed September 2022. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety6.html