C9：减少诊断错误的策略和集体行动.pdf

1、STRATEGIES AND COLLECTIVE STRATEGIES AND COLLECTIVE ACTION TO REDUCE DIAGNOSTIC ACTION TO REDUCE DIAGNOSTIC ERRORSERRORSMay 22,2025BMJ IHI Forum for Quality and SafetyL.zwaanerasmusmc.nlHardeep Singh&Laura Zwaan10-15%of the diagnoses are not entirely correct 1Most people will experience a diagnostic

2、 error in their lifetime 2Highly preventable and high mortality rates3,4Prevalent in malpractice claims 4The burden of diagnostic errorsThe burden of diagnostic errors1.Berner&Graber,Am J Med,20082.National Academies of Medicine,20153.Zwaan et al.Arch Intern Med,20104.Bishop et al.JAMA,2011Patient S

3、afety PriorityPatient Safety PriorityNational Academy of Medicine ReportDiagnostic Safety WHO world patient safety dayDiagnostic error Diagnostic error researchresearchBurdenCausesInterventionsIncidence rates of diagnostic errorHigh risk diseasesHigh risk settingsHarmFactors contributing to diagnost

4、ic error:Human errorSystemContextEfforts to reduce diagnostic error:EducationSystem improvementTeamworkPatient involvementHealth ITWhat is a diagnostic What is a diagnostic error?error?DefinitionbyDiagnostic errorA diagnosis that was unintentionally delayed,wrong,or missed,as judged from the eventua

5、l appreciation of more definitive information.Graber,2005Missed opportunitiesMissed opportunities to make a correct or timely diagnosis based on the available evidence,regardless of patient harm.Singh,2014 Diagnostic errorthe failure to(a)establish an accurate and timely explanation of the patients

6、health problem(s)or(b)communicate that explanation to the patient.NAM,2015Diagnostic discrepancyA difference between the diagnosis made at the time of patient admission(or initial evaluation)and the diagnosis established at the end of the hospital stay(discharge or follow-up)Hautz,2019Diagnostic Adv