绘制诊断安全图:在医疗记录文档中探索患者和医疗服务提供者的矛盾
Traber D Giardina1, Viral Vaghani2, Divvy K Upadhyay3
1Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC) and Department of Medicine, Baylor College of Medicine, 2002 Holcombe Boulevard, Houston, TX, 77030, USA. traberd@bcm.edu.
Journal of general internal medicine
|September 5, 2024
概括
患者和临床医生对诊断问题的理解往往不同. 改善诊断安全需要将患者的观点纳入过程.
科学领域:
- 医疗信息学 医疗信息学
- 患者安全 患者安全
- 诊断的准确性 诊断的准确性
背景情况:
- "21世纪疗法法" (the 21st Century Cures Act) 旨在促进患者获取医疗记录.
- 这种访问为患者参与诊断提供了机会.
研究的目的:
- 评估患者报告的诊断问题与临床医生在电子健康记录中的解释之间的一致性.
- 发现患者和临床医生之间理解诊断过程中的差异.
主要方法:
- 使用Safer Dx Patient仪器对467名患者进行混合方法分析.
- 开放式答复和临床医生笔记的定性内容分析.
- 盲目临床审稿人使用修订后的更安全的Dx仪器进行独立的图表审查.
- 多变量逻辑回归用于比较患者报告和临床医生确定的问题.
主要成果:
- 图表审查发现了31个诊断问题;只有21.5%的重叠与51个患者报告的问题.
- 定性分析显示,患者和临床医生对诊断过程的理解有所不同.
- 临床医生确定的担忧与患者感到诊断不正确相关 (OR 1.65).
结论:
- 患者和临床医生在诊断问题上表现出不同的心理模型.
- 整合患者的观点对于加强诊断安全测量至关重要.
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