Diagnostic safety in the State of Qatar Successes & Challenges - - PowerPoint PPT Presentation

Diagnostic safety in the State of Qatar Successes & Challenges

Wanis H Ibrahim FRCP (Edin), FRCP (Glasg), FRCP (Ire), FCCP, F (Pulm) Senior Consultant Physician Hamad General Hospital Professor of Clinical Medicine Qatar University & Weill-Cornell –Qatar Doha/Qatar

ﺑﺳم ﷲ اﻟرﺣﻣن اﻟرﺣﯾم

I have no conflict of interest to disclose

Objectives

• Successes in diagnostic

safety in the State of Qatar (HMC)

• Challenges in providing

a safe diagnostics

Case of Mrs. M From old HMC medical records

• Mrs. M, a 46-year-old presented to one of the HMC hospitals ED in a very busy night complaining

from right upper abdominal pain. The pain was severe and preventing her from taking deep

• breath. She was assessed by an ED junior doctor who was suspecting acute cholecystitis because
• f tender RHC with a positive Murphy’s sign. Patient did not have leukocytosis or fever. US

abdomen showed a suspicion of GB polyp. GS resident on call was consulted. He ordered HIDA

• scan. Second day while in ED, patient’s daughter informed the nurse that her mother’s breathing

was not normal. Another ED physician who did not receive endorsement from the previous colleague found the patient to be hypotensive with low O2 saturation. A suspicion of septic shock was made and fluid resuscitation/antibiotics were administered. The assigned nurse noticed that the patient's right leg was swollen. A senior ED physician evaluated the patient and suspected a pulmonary embolism causing a referred RHC pain. An urgent CTPA (which was delayed for 6 hours) confirmed a massive pulmonary embolism with a right pulmonary infarction. Patient was admitted to ICU because of hypoxemic respiratory failure and hypotension and received thrombolytic therapy.

• Q1. What factors were responsible for the delay in diagnosis of this patient?
• Q2. What risks were/could have been encountered because of delayed PE diagnosis?

• Comprehensive reforms in health care system.
• Comprehensive World-Class Healthcare System - 2030

Goals for improving diagnosis & reducing diagnostic errors

• Facilitate more effective teamwork in the diagnostic process among health care

professionals, patients, and their families

• Enhance health care professional education and training in the diagnostic process
• Ensure that health information technologies support patients and health care

professionals in the diagnostic process

• Provide correct approaches of minimizing diagnostic errors through teaching and

education (Not punitive/threatening approaches)

• Establish a work system and culture that supports the diagnostic process and

improvements in diagnostic performance

• Develop a reporting environment and medical liability system that facilitates

improved diagnosis by learning from diagnostic errors and near misses

• Design a payment and care delivery environment that supports the diagnostic

process

• Provide dedicated funding for research on the diagnostic process and diagnostic

errors The National Academies of Sciences, Engineering and Medicine. Improving Diagnosis in Health Care (2015). The National Academies Press, Washington, DC. www.nap.edu

Clinician process in diagnosis

v Clinician process and team work is one of the most crucial steps to achieve a reliable diagnosis. v Diagnosis remains fundamentally dependent on:

• A personal interaction of a

[clinician] with a patient

• The sufficiency of communication

between them

• The accuracy of the patient’s

history and physical examination, and

• The cognitive energy necessary to

synthesize a vast array of information”

Kassirer, J. P. 2014. Imperatives, expediency, and the new diagnosis. Diagnosis 1(1):11–12.

Proficiency in clinical reasoning

• Clinical reasoning: is “the cognitive process

that is necessary to evaluate and manage a patient’s medical problems”

• Accurate, timely, and patient-centered

diagnosis relies heavily on proficiency in clinical reasoning, which is often regarded as the clinician’s quintessential competency.

Barrows HS, Tamblyn RM. Problem-based learning. An approach to medical education. New York: Springer; 198

Changes in medical team structure (HMC)

• Shift from consultant-led service

to consultant-delivered service

• Consultants are available 24

hours in-house

• Consultants are required to

counter-sign all resident entries

• Consultants are required to

document their own notes at patient’s admission and at least twice per week.

• Continuous consultant

supervision of junior doctors during in-patient and out-patient services

Enhancing Health Care Professional Education and Training in the Diagnostic Process & clinical reasoning at HMC

• Lack of focus on developing clinical

reasoning and understanding the cognitive contributions to decision making represents a major gap in education within all health care professions.

• Doctors-in-training at HMC are

required to pass strict clinical exams that test their diagnostic & clinical reasoning abilities

• Clinical courses are regularly

conducted to improve diagnostic and clinical reasoning abilities among physicians-in-training at HMC

Inter-professional collaboration & patient engagement

• Regular organization of Multidisciplinary Team (MDT)

Care Meetings and Rounding at HMC

• Use of standardized communication techniques for

critical information (SBAR)

• Communication training courses
• MDT – Patient/family meetings
• Second opinion availability
• Patient access to electronic health records, including

clinical notes and diagnostic testing results

• HMC clinical guidelines and policies

Clinical guidelines and policies (HMC)

Improvement in Health Information Technologies at HMC

• Health IT has the potential to improve

diagnosis and reduce diagnostic errors by facilitating timely and easy access to information; communication among health care professionals, patients, and their families; clinical reasoning; and feedback and follow-up in the diagnostic process.

Improvement in Laboratory services (HMC)

• The laboratory has state-of-the-art testing

facilities

• The laboratory provides timely, accurate and

appropriate pathology services in support of patient care.

• Results of urgent tests, such as those from the

emergency department, operating theatres, and intensive care units, are given special attention and reported in a very short time

• Point of Care Testing, which is testing at or near

the site of patient care, is available

• The laboratory department is accredited by CAP

Histopathology specimens

• All surgical pathology reports are released in an appropriate and timely manner in order to achieve

high standards in patient care.

• Turnaround time (TAT) is as measured in working days from the time the specimen is received in

the laboratory to the time the verbal report is available or the final report is released.

• In measurement of TAT, Specimens requiring more tests, prolonged fixation, decalcification, special

stains, immunohistochemistry, outside consultation will require longer turnaround time.

• TAT for STAT tests:
• Frozen Section 20 minutes/block (90% threshold)
• "Renal Transplant biopsy

Preliminary Report within 24 – 48 hours "

• TAT for routine tests:

GI Biopsies / Liver 3 days Renal biopsy 5 days All tissue specimens (biopsied, small and medium size resection) 5 day Large specimen or extra fixative 7 days Bone 10 days

• Critical values such as cancer cases are reported to focal point to contact the requesting physician

Improvement in Radiology services

• All state-of-art radiologic facilities including both

diagnostic and interventional radiology services are available at HMC

• Urgent cases and cancer cases are given priority
• In-patient:

Preliminary report is available in few hours Final report in 48 hours

• Out-patient:

Non-urgent: final report in 5 days

• Red flags/critical results are immediately reported to

a focal point to contact the treating physician

Monitoring of the diagnostic process

• Conducting analyses of

diagnostic errors, near misses, and adverse events presents the best

• pportunity to learn from

such experiences and implement changes to improve diagnosis.

• Provide safe environments,

without the threat of legal discovery or disciplinary action, to analyze and learn from these events. HMC

• Quality improvement

programs

• Patient safety programs
• Supervision monitoring
• Monitoring adherence to

HMC policies & guidelines

• Adverse event reporting
• Morbidity & Mortality MDT

Shortage in diagnostic research

• Despite the tremendous improvement in

clinical research in the State of Qatar, diagnosis and diagnostic errors are not a focus

• f HMC research efforts. Research at HMC is

usually disease-focused.

Collaboration among health care facilities

• The diagnostic process hinges on successful intra-

and inter-professional collaboration among health care professionals, including primary care clinicians, physicians in various specialties, nurses, pharmacists, technologists, therapists, social workers, patient navigators, and many

• thers.
• Although such collaboration exists among HMC

tertiary care facilities, there is significant shortage in coordination between primary care and tertiary care centers

Other important challenges

• Shortage in proper communication particularly during

transfers

• Lack of continuity of care
• Short time in the clinics
• Long waiting time to see physicians in the clinic
• Time pressure/busy hospital
• Bed situation and pressure to discharge
• Patient factor: reliability of history
• Diagnostic safety in private sector is unknown
• Poorly developed primary care system: over-reliance on ED
• Autopsy rarely performed (limited feedback to clinicians

about diagnostic performance)

Case of Mrs. M From HMC medical records

• Mrs. M, a 46-year-old presented to one of the HMC hospitals ED in a very busy night complaining from right

upper abdominal pain. The pain was severe and preventing her from taking deep breath. She was assessed by an ED junior doctor who was suspecting acute cholecystitis because of tender RHC with a positive Murphy’s sign. Patient did not have leukocytosis or fever. US abdomen showed a suspicion of GB polyp. GS resident on call was consulted. He ordered HIDA scan. Second day while in ED, patient’s daughter informed the nurse that her mother’s breathing was not normal. Another ED physician who did not receive endorsement from the previous colleague as acute cholecystitis case found the patient to be hypotensive with low O2 saturation. A suspicion of septic shock was made and fluid resuscitation/antibiotics were

• administered. The nurse who was assigned to the patient noticed that the patient's right leg was swollen. A

senior ED physician evaluated the patient and suspected a pulmonary embolism causing a referred RHC

• pain. An urgent CTPA (which was delayed for 6 hours) confirmed a massive pulmonary embolism with a

right pulmonary infarction. Patient was admitted to ICU because of hypoxemic respiratory failure and hypotension and received thrombolytic therapy.

• Q1. What factors were responsible for the delay in diagnosis of this patient?

1. Lack of effective teamwork – role of the nurse 2. Incomplete communication during care transitions 3. Shortage in proficiency in clinical reasoning 4. Shortage in inter-professional communication 5. Time issue and work load 6. Involvement of family/patient

• Q2. What risks were/could have been encountered because of delayed PE diagnosis?

1. Acute hypoxemic respiratory failure 2. Circulatory shock/collape 3. Thrombolytic –bleeding 4. Death

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