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General lnternal Medicine Patient Safety Diagnostic Errors Reasoning errors can lead to diagnostic errors. STUDY TABLE: Reasoning Errors Heuristic Definition Availability Clinician has encountered a similar presentation and jumps to the conclusion that the current diagnosis must be the same as the previous. Anchoring Clinician accepts at face value a previous diagnosis made by another clinician. Blind obedience Clinician accepts a diagnosis or plan made by another of higher authority. Premature closure Full differential diagnosis is not considered. Error Analysis Root cause analysis is an exercise used to determine the contributors to an adverse event. Often, a cause eflect "fishbone" diagram is used to illustrate causation, beginning with a problem or error at the fish's head. Working back down the spine, the team is asked repetitively, 'And what contributed to this?" This continues until as many prime factors as possible are identified. Ouality lmprovement A common methodologr to improve quality is the Plan Do Study Act (PDSA) cycle. The clinician might plan a test of quality improvement, do the test by trying the new protocol on a limited number of patients, study the results, and act by refining the protocol based on what was learned and planning the next test. Patient Handoffs The best practice for handoff includes person to person communication, providing an opportunity to ask and respond to ques- tions, and providing information that is accurate and concise (including name, location, history diagnoses, severity of illness, medication and problem lists, status, recent procedures, a "to do" list that has "iflthen" statements, and contingency plans).

Patient Handoffs The best practice for handoff includes person to person communication, providing an opportunity to ask and respond to ques- tions, and providing information that is accurate and concise (including name, location, history diagnoses, severity of illness, medication and problem lists, status, recent procedures, a "to do" list that has "iflthen" statements, and contingency plans). Health I nformation Tech nology The EHR, CPOE, and computerized CDS are some common examples of health information technologies. CPOE is a system by which clinicians electronically enter medication, radiologz, and laboratory orders, thereby eliminating errors and delays related to illegible handwriting. CDS refers to the use of information technologi to facilitate clinical decision making. When integrated into a CPOE system, CDS can highlight potential contraindications to diagnostic tests, specify dose recommendations, identify potential drug interactions, and suggest modifications to drug dosage in patients with kidney or liver dysfunction. CDS within the EHR can also promote protocols to improve care and provide ready access to clinical guidelines. Perioperative Medicine Preoperative Testing Routine diagnostic testing is not indicated preoperatively. Do not obtain: o routine preoperative laboratory studies in healthy patients undergoing elective or low-risk surgery o preoperative chest radiography in the absence of cardiopulmonary symptoms 147