Standort in Deutschland, wo man günstige und qualitativ hochwertige Kamagra Ohne Rezept Lieferung in jedem Teil der Welt zu kaufen.

Kaufen priligy im Online-Shop. Wirkung ist gut, kommt sehr schnell, innerhalb von 5-7 Minuten. cialis was nur nicht versucht, verbrachte eine Menge Geld und Nerven, und geholfen hat mir nur dieses Tool.

Checklists to Reduce Diagnostic Errors
John W. Ely, MD, Mark L. Graber, MD, and Pat Croskerry, MD, PhD
evaluation. The purpose of this article is often be traced to physicians’ cognitive to argue for the further investigation and describes three types of checklists: (1) a revision of these initial attempts to apply general checklist that prompts physicians checklists to the diagnostic process. The to optimize their cognitive approach, (2) basic idea behind checklists is to provide to error, but little is known about how to a differential diagnosis checklist to help an alternative to reliance on intuition and of diagnostic error—failure to consider the correct diagnosis as a possibility, and Editor’s Note: A commentary on this article appears they are well integrated in the workflow, Cognitive Processes in Diagnosis
suggestions include reflective practice8,9 recognize flaws in the intuitive “thinking” psychology related to the “dual-process” 1).18 This model proposes two basic modes and more likely to result in patient harm than are other types of medical errors.3,4 Given their success in other settings, it is reflexive, intuitive, and may operate at a subconscious level. We perform many tasks might help reduce diagnostic errors.
Checklists are used by airline pilots in all system-based problems are relatively easy routinely until the crash of a Boeing 299 they are repeated on a regular basis, these release the elevator locks.11 Checklists are subconscious level, and if everything is as it Dr. Ely is professor, Department of Family Medicine,
University of Iowa, Iowa City, Iowa.
used by other high-risk, high-reliability seems, we perform well. In contrast, Type 2 processes are analytic, slow, and deliberate.
Dr. Graber is chief of medicine, Department of
Veterans Affairs Hospital, Northport, New York, andprofessor and associate chair, Department of Internal Medicine, State University of New York, Stony Brook, Dr. Croskerry is professor of emergency medicine,
Dalhousie University, Halifax, Nova Scotia, Canada.
intensive care unit staff use checklists to Correspondence should be addressed to Dr. Ely, Department of Family Medicine, 01291-D, PFP, clinical situations that seem familiar, we University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242; telephone: (319) 384-7533; fax: (319) 384-7822; e-mail: john- surgical deaths by half after introducing a checklists prove effective. For diagnosis, The purpose of this article is to describe a generic checklists could force a reflective First published online January 18, 2011doi: 10.1097/ACM.0b013e31820824cd potential role for checklists in avoiding check, and specific checklists could force Supplemental digital content for this article isavailable at
Academic Medicine, Vol. 86, No. 3 / March 2011 “upstream” problems—those involving previous encounters—such assuccumbing to the framing bias imparted RECOGNIZED
it is proposed and communicated, to theextent that subsequent physicians may Calibration†
discount or fail to consider other possible Processor
“groupthink,” in which the chances oferror increase when the impressions of RECOGNIZED
Figure 1 A model for diagnostic reasoning based on dual-process theory. Adapted with
permission from Croskerry P. A universal model for diagnostic reasoning. Acad Med. 2009;84:1022–1028. Type 1 thinking can be influenced by multiple factors, many of them subconscious Perform a focused and purposeful
(emotional polarization toward the patient, recent experience with the diagnosis being physical exam. The initial hypotheses
considered, specific cognitive or affective biases), and is therefore represented as multiple- channeled, whereas Type 2 processes are, in a given instance, single-channeled and linear. Type 2override of Type 1 (executive override) occurs when physicians take a time-out to reflect on their thinking, possibly with the help of checklists. In contrast, Type 1 may irrationally override Type 2 (dysrationalia override) when physicians insist on going their own way (e.g., ignoring evidence- based clinical decision rules that can usually outperform them).
special attention. However, we must alsolook for signs that might suggest alternate * “Dysrationalia” denotes the inability to think rationally despite adequate intelligence.68† “Calibration” denotes the degree to which the perceived and actual diagnostic accuracy correspond.
Checklists could help us resist the biases errors in hospitals, clinics, and emergency Generate and differentiate initial
hypotheses with further history,
physical exam, and diagnostic tests.
insultingly obvious (e.g., “Obtain your improving diagnostic reasoning.2,10 Using own complete history”), but their routine problems related to diagnostic testing,26 for most physicians. After all, pilots no their copilots to release the elevator locks.
• consider a comprehensive differential The general checklist
posttest period, occurring at rates of 10% reproducible approach to diagnosis.21 List 1 offers an example of such a checklist.
• develop strategies to avoid predictable Pause to reflect—take a diagnostic
“time-out.” Short of seeking a second
• recognize our altered mood states that arise from fatigue, sleep deprivation, or plausibility of the working diagnosis may be our best tool to avoid error.8,9 The two context errors and premature closure.5,26 Context errors arise when a critical signalis distorted by the background against Diagnostic Checklists
Obtain your own complete medical
which it is perceived.24 A typical context Here, we describe three types of checklists history. There is no substitute for
Academic Medicine, Vol. 86, No. 3 / March 2011 Table 1
Cognitive Biases and Failed Heuristics Addressed by Diagnostic Checklists
Bias or heuristic
Role of checklist
The tendency to perceptually lock on to salient features Prompt physician to consider diagnoses other than the of the patient’s presentation too early in the diagnostic process and failing to adjust this impression in light oflater information.
The disposition to judge things as being more likely or Prompt physician to consider diagnoses other than frequently occurring, if they readily come to mind.
The tendency to ignore the true prevalence of a Remind physician of the relative prevalence of diseases disease, either inflating or reducing its base rate and in primary care for the patient’s complaint.
The decision-making process ends too soon; the Prompt physician to reopen the diagnostic process and diagnosis is accepted before it has been fully verified.
consider alternative diagnoses before discharging the “When the diagnosis is made, the thinking stops.” The physician looks for prototypical manifestations of Prompt physician to consider causes for the symptoms disease (pattern recognition) and fails to consider other than the ones that readily fit the pattern.
The tendency to call off a search once something is Prompt physician to consider additional causes of the The failure to elicit all relevant information in Prompt physician to ask questions that might confirm establishing a differential diagnosis.
The critical signal is distorted by the background Encourage physician to rethink assumptions and * Source: Croskerry P. Cognitive and affective dispositions to respond. In: Croskerry P, Cosby K, Schenkel S, Wears R, eds. Patient Safety in Emergency Medicine. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009:219 –227.
other decisions may take priority, such as patient’s presentation often changes over Differential diagnosis checklists
diagnostic errors is our failure to consider and write “NYD” (not yet diagnosed) in • Consider the opposite: “Why can’t this be something else?” Tests that rule out diagnostic label until our certainty is high • Use “prospective hindsight”: Derived Embark on a plan, but acknowledge
Proposed General Checklist for

uncertainty and ensure a pathway for
follow-up.37,38 We often just play the
• Obtain your own complete medical history.
• Perform a focused and purposeful physical Certainty is not a realistic possibility. The correct diagnosis often emerges over time as test results become available or as the differentiate these with additional history, patient’s symptoms and signs evolve. This physical exam, and diagnostic tests.
• Apply decision support tools: A growing longitudinal aspect of diagnosis mandates • Pause to reflect—take a diagnostic “time that we reconsider an initial diagnosis at diagnosis generators are available, such as ⅙ Was my judgment affected by any other uncertainties, and lay out a concrete plan ⅙ Do I need to make the diagnosis now, or ensuring follow-up is a strategy that can help improve the reliability of diagnosis uncertainty and ensure a pathway for Academic Medicine, Vol. 86, No. 3 / March 2011 highlighted in List 2 and detailed in the dizziness, and so on. The checklists were revised during two years of use in clinic.
to consider a comprehensive list of causes of the differential diagnosis checklist is differential diagnosis checklists, but one of the authors (J.E.) has noted anecdotal checklists highlight diagnoses that should not be missed and those that are, in fact, checklists in practice. For example, a 90- anatomy,43,45,46,48 pathophysiology,41,45 after two albuterol nebulizer treatments, dyspnea. She had been seen four daysearlier with a “COPD exacerbation” and Example of Differential Diagnosis
to cover 100% of presenting complaints.
Sinus tachycardia
checklists. And within each checklist, our goal was to cover at least 99% of patients • Chronic obstructive pulmonary disease • Pregnancy (10 to 20 beats per minute at such as constipation and breast lumps.
that did not alter the initial diagnosis and withdrawal, bupropion, caffeine, cilostazol, cocaine, ephedrine, epinephrine,isoproterenol, nicotine, tobacco)† Cognitive forcing checklists for specific
“pneumococcal pneumonia,” “klebsiella Checklists can serve as cognitive forcing “right-upper-quadrant pain,” “right- because we wanted to avoid redundancy.
until the card is removed. Thus, the error avoided. If the checklist is always built into diagnostic thinking, then it becomes generic or specific. In the generic sense, “ROWS” (rule out worst-case scenario) • Postural orthostatic tachycardia syndrome possibilities always receive consideration.
• Chronic nonparoxysmal sinus tachycardia checklist at the time of admission to help In the specific sense, checklists may help determine whether further history taking, avoid predictable pitfalls for particular * “Don’t-miss” diagnosis.
† Commonly missed diagnosis.
Academic Medicine, Vol. 86, No. 3 / March 2011 address treatment rather than diagnosis.
Example of a Disease-Specific
Cognitive Forcing Checklist
Ankle injury
enough face validity to make such testing questioned the ethics of allowing patients to participate in a usual-care arm (i.e., no safety intervention) in clinical trials of ⅙ Peroneal tendon syndromes (tendinitis, checklists before adopting them. Instead, most likely for a particular patient.
⅙ Consider stress films for ankle stability not been widely adopted in practice,52,53 checklists may have a greater potential for harm than preflight or surgical checklists.
knowledge base,6 they can be difficult to For example, they could lead to excessive incorporate into the workflow,6,54–56 and consultation or needless testing (although most serious errors result from doing too Other interventions similar to checklists ⅙ Missed neurovascular injury (suspect if ⅙ Missed associated fracture (especially (mental checklists).62 These interventions learned not to rely on their memories. In contrast, physicians value superior recall ⅙ Missed Maisonneuve fracture (proximal organizational structures that differ from ⅙ Missed Achilles tendon rupture (partial or than mental crutches, reflective thought, Limitations of checklists
⅙ Missed complex regional pain syndromes Recent success in adapting preflight-style stories, but they don’t make great health checklists for diagnosis may be a “bridge too far.” The analogy between actionable forcing strategies will inevitably focus on intensive care units, or even airplanes.
procedures in diagnosis is not tight.
Thoughts are less tangible than actions, Checklists could produce a false sense ofreassurance that leads to complacency, Further Considerations and
whether they have been completed. Inboth medical and nonmedical settings, checklists are read aloud by teams rather checklists as a concept that might reduce aspects of care unrelated to diagnosis.
diagnosis is usually silent, lonely work, Similar concerns were raised with clinical and a natural pause point11 to review the algorithms. It was feared that physicians kinds of checklists, which we have used in checklist, such as before takeoff or before data to support these concerns whenalgorithms were studied in practice.65,66 Related studies
Diagnostic support tools include practice checklists in this article were not derived affective state. But rather than unfocused Academic Medicine, Vol. 86, No. 3 / March 2011 “thunderclap” headache, “worst-ever” 12 Karl R. Briefings, checklists, geese, and
13 Reason J. Human Error. Cambridge,
England: Cambridge University Press; 1990.
an active diagnostic time-out, I reviewed failure to consider the correct diagnosis 14 Pronovost P, Needham D, Berenholtz S, et al.
An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl 15 Gawande A. The checklist. The New Yorker.
16 Berenholtz SM, Pronovost PJ, Lipsett PA, et
al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care 17 Haynes AB, Weiser TG, Berry WR, et al. A
Acknowledgments: The authors are indebted to surgical safety checklist to reduce morbidityand mortality in a global population. N Engl Conclusions
Amy Miranda, Grace Garey, Mary-Lou Glazer,and Wendy Isser for their expert administrative 18 Sloman S. The empirical case for two systems
of reasoning. Psychol Bull. 1996;119:3–22.
19 Croskerry P. Clinical cognition and
process model of reasoning. Adv Health Sci Educ Theory Pract. 2009;14(suppl 1):27–35.
Ethical approval: Not applicable.
for checklists? (3) Who should review the 20 Croskerry P. Cognitive and affective
dispositions to respond. In: Croskerry P,Cosby K, Schenkel S, Wears R, eds. Patient References
Safety in Emergency Medicine. Philadelphia, Will checklists be valued or even accepted 1 Elstein AS. Clinical judgment: Psychological
Pa: Lippincott Williams & Wilkins; 2009: research and medical practice. Science. 1976; 21 Graber ML. Educational strategies to reduce
2 Berner ES, Graber ML. Overconfidence as a
diagnostic error: Can you teach this stuff? cause of diagnostic error in medicine. Am J 3 Bhasale AL, Miller GC, Reid S, Britt HC.
22 Hayward RA, Asch SM, Hogan MM, Hofer
TP, Kerr EA. Sins of omission: Getting too little medical care may be the greatest threat study. Med J Aust. 1998;169:73–76.
to patient safety. J Gen Intern Med. 2005;20: 4 Leape LL, Brennan TA, Laird N, et al. The
23 Croskerry P. Timely recognition and
diagnosis of illness. In: MacKinnon N, ed.
Practice Study II. N Engl J Med. 1991;324: 5 Graber ML, Franklin N, Gordon R.
Checklists are mandatory for pilots.
System. Ottawa, Ontario, Canada: Canadian Diagnostic error in internal medicine. Arch Pharmacists Association; 2007:79 –93.
24 Croskerry P. Context is everything or how
6 Miller RA. Computer-assisted diagnostic
could I have been that stupid? Healthc Q.
decision support: History, challenges, and 2009;12 Spec No Patient:e171–e176.
reasonable if they can be shown to work.
25 Taleb NN. The Black Swan. New York, NY:
Pilots do not have the option of skipping 26 Schiff GD, Hasan O, Kim S, et al. Diagnostic
7 Rosenbloom ST, Geissbuhler AJ, Dupont
error in medicine: Analysis of 583 physician- (sunny day, familiar airport, experienced reported errors. Arch Intern Med. 2009;169: design on user-initiated access toeducational and patient information during physicians to “use this checklist exactly clinical care. J Am Med Inform Assoc. 2005; 27 Kachalia A, Gandhi TK, Puopolo AL, et al.
when you think you don’t need it” will likely be met with skepticism. It would be 8 Singh H, Petersen LA, Thomas EJ.
emergency department: A study of closedmalpractice claims from 4 liability insurers.
Understanding diagnostic errors in medicine:A lesson from aviation. Qual Saf Health Care.
28 Plebani M. Exploring the iceberg of errors in
9 Mamede S, Schmidt HG, Rikers R. Diagnostic
laboratory medicine. Clin Chim Acta. 2009; errors and reflective practice in medicine.
might identify “red flags” that should J Eval Clin Pract. 2007;13:138 –145.
29 Elstein AS. Clinical reasoning in medicine. In:
Higgs J, Jones MA, eds. Clinical Reasoning in prompt a time-out and checklist review.
10 Croskerry P. The importance of cognitive
errors in diagnosis and strategies to minimize Generic red flags might include failure to Butterworth-Heinemann; 1995:49 –59.
respond to initial treatment, second visit 30 Mitchell DJ, Russo JE, Pennington N. Back to
explanation of events. J Behav Decis Making.
11 Gawande A. The Checklist Manifesto—How
31 Kahneman D, Klein G. Conditions for
diagnostic errors. Complaint-specific red intuitive expertise: A failure to disagree. Am Academic Medicine, Vol. 86, No. 3 / March 2011 32 Wears RL. What makes diagnosis
47 Smith DS. Field Guide to Bedside Diagnosis.
59 McPhee SJ, Bird JA, Fordham D, Rodnick JE,
hard? Adv Health Sci Educ Theory Pract.
Philadelphia, Pa: Lippincott Williams & activities by primary care physicians. Results 33 Kovacs G, Croskerry P. Clinical decision
48 Louis AA. Handbook of Difficult Diagnosis.
of a randomized, controlled trial. JAMA.
making: An emergency medicine perspective.
New York, NY: Churchill Livingstone; 1990.
49 Lewis C, Norman DA. Designing for error.
60 Balas EA, Weingarten S, Garb CT,
34 Campbell SG. Advances in emergency
In: Norman D, Draper S, eds. User Centered medicine: A 10-year perspective. Can J Diag.
System Design: New Perspectives in Human- physicians. Arch Intern Med. 2000;160:301– 35 Croskerry P. Avoiding pitfalls in the
emergency room. Can J Contin Med Educ.
50 Wilson RM, Runciman WB, Gibberd RW,
61 Marill KA, Gauharou ES, Nelson BK,
Peterson MA, Curtis RL, Gonzalez MR.
36 Vickers AJ, Basch E, Kattan MW. Against
Quality in Australian Health Care Study. Med Prospective, randomized trial of template- diagnosis. Ann Intern Med. 2008;149:200 – assisted versus undirected written recording 51 Newman-Toker DE, Pronovost PJ.
37 Schiff GD. Minimizing diagnostic error: The
Diagnostic errors—The next frontier for department. Ann Emerg Med. 1999;33:500 – importance of follow-up and feedback. Am J patient safety. JAMA. 2009;301:1060 –1062.
52 Trowbridge R, Weingarten S. Clinical
62 Lieberman P, Decker W, Camargo CA Jr,
38 Redelmeier DA. Improving patient care. The
decision support systems. In: Shojania K, Oconnor R, Oppenheimer J, Simons FE.
cognitive psychology of missed diagnoses.
Duncan B, McDonald K, Wachter R, eds.
Making Health Care Safer: A Critical Analysis 39 Crandall B, Wears RL. Expanding
of Patient Safety Practices. Rockville, Md: department. Ann Allergy Asthma Immunol.
perspectives on misdiagnosis. Am J Med.
Agency for Healthcare Research and Quality; 63 Leape LL, Berwick DM, Bates DW. What
40 Shojania KG, Burton EC, McDonald KM,
53 Payne TH. Computer decision support
practices will most improve safety? Evidence- systems. Chest. 2000;118(2 suppl):47S–52S.
based medicine meets patient safety. JAMA.
54 Patterson ES, Doebbeling BN, Fung CH,
systematic review. JAMA. 2003;289:2849 – Militello L, Anders S, Asch SM. Identifying 64 Gaither C. What your doctor doesn’t know
barriers to the effective use of clinical could kill you. Boston Globe. July 14, 2002.
41 Adler SN, Adler-Klein D, Gasbarra DB. A
reminders: Bootstrapping multiple methods.
Pocket Manual of Differential Diagnosis. 5th J Biomed Inform. 2005;38:189 –199.
ed. Philadelphia, Pa: Lippincott Williams & 55 Bates DW, Kuperman GJ, Wang S, et al. Ten
commandments for effective clinical decision 65 McDonald CJ, Wilson GA, McCabe GP Jr.
42 Greenberger NJ. Handbook of Differential
support: Making the practice of evidence- Physician response to computer reminders.
Diagnosis in Internal Medicine: Medical Book based medicine a reality. J Am Med Inform of Lists. 5th ed. St. Louis, Mo: Mosby; 1998.
66 Shoemaker WC, Corley RD, Liu M, et al.
43 Wiener SL. Differential Diagnosis of Acute
56 Johnson CW. Why did that happen?
Development and testing of a decision tree Exploring the proliferation of barely usable for blunt trauma. Crit Care Med. 1988;16: 44 Stern S, Cifu A, Atkorn D. Symptom to
Health Care. 2006;15(suppl 1):i76 –i81.
67 Friedman CP, Gatti GG, Franz TM, et al. Do
Diagnosis: An Evidence-Based Guide. 2nd ed.
57 Graber MA, VanScoy D. How well does
correct? Implications for decision support 45 Siegenthaler W. Differential Diagnosis in
and error reduction. J Gen Intern Med. 2005; 58 Garg AX, Adhikari NK, McDonald H, et al.
Reference cited only in figure
Effects of computerized clinical decision 46 Collins RD. Differential Diagnosis in Primary
support systems on practitioner performance 68 Stanovich KE. Dysrationalia: A new specific
Care. 4th ed. Philadelphia, Pa: Lippincott and patient outcomes: A systematic review.
learning disability. J Learn Disabil. 1993;26: Academic Medicine, Vol. 86, No. 3 / March 2011



Gabapentin Important drug interactions Clinical use Anti-epileptic – adjunctive treatment of partial• Antidepressants: antagonism of anticonvulsiveseizures with or without secondary generalisation Administration Dose in normal renal function 300 mg on day 1, 300 mg twice daily on day 2,300 mg three times daily on day 3, then increasedaccording to response to 1.2 g daily (in t

Patient Registration Name__________________________________ Birthdate __________________ Age ______ Sex M / FSocial Security # ________________________ Address______________________________________________________________________________Patient’s Employer __________________________________________ Occupation ______________________Employer Address ________________________________________

Copyright © 2010-2014 Internet pdf articles