Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, ‘Improving Diagnosis in Health Care’, concluded that most people will likely experience a diagnostic error in their lifetime. In this narrative review, we discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. We synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. We then summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors. Research suggests that we are unlikely to find a ‘magic bullet’ and confirms the need for a multifaceted approach to understand and address the many systems and cognitive issues involved in diagnostic error. Because errors involve many common conditions and are prevalent across all countries, the WHO’s leadership at a global level will be instrumental to address the problem. Based on our review, we recommend that the WHO consider bringing together primary care leaders, practicing frontline clinicians, safety experts, policymakers, the health IT community, medical education and accreditation organizations, researchers from multiple disciplines, patient advocates, and funding bodies among others, to address the many common challenges and opportunities to reduce diagnostic error. This could lead to prioritization of practice changes needed to improve primary care as well as setting research priorities for intervention development to reduce diagnostic error.
Avoiding low value care received increasing attention in many countries, as with the Choosing Wisely campaign and other initiatives to abandon care that wastes resources or delivers no benefit to patients. While an extensive literature characterises approaches to implementing evidence-based care, we have limited understanding of the process of de-implementation, such as abandoning existing low value practices. To learn more about the differences between implementation and de-implementation, we explored the literature and analysed data from two published studies (one implementation and one de-implementation) by the same orthopaedic surgeons. We defined ‘leaders’ as those orthopaedic surgeons who implemented, or de-implemented, the target processes of care and laggards as those who did not. Our findings suggest that leaders in implementation share some characteristics with leaders in de-implementation when comparing them with laggards, such as more open to new evidence, younger and less time in clinical practice. However, leaders in de-implementation and implementation differed in some other characteristics and were not the same persons. Thus, leading in implementation or de-implementation may depend to some degree on the type of intervention rather than entirely reflecting personal characteristics. De-implementation seemed to be hampered by motivational factors such as department priorities, and economic and political factors such as cost-benefit considerations in care delivery, whereas organisational factors were associated only with implementation. The only barrier or facilitator common to both implementation and de-implementation consisted of outcome expectancy (ie, the perceived net benefit to patients). Future studies need to test the hypotheses generated from this study and improve our understanding of differences between the processes of implementation and de-implementation in the people who are most likely to lead (or resist) these efforts.
The resolve to put patients at the heart of the National Health Service (NHS) has been ubiquitous in the aftermath of the Francis Report, and the policy agenda is beginning to reflect attempts to deliver that promise. The introduction of new care models at NHS ‘vanguard’ sites, the 3-year target to give all patients access to their electronic care records, and the expansion of integrated care services all exemplify the salience of patient-centricity at the national level.1 This pattern has been witnessed across many developed health systems.2
The ideals of this paradigm have also captured the attention of local commissioners and providers, offering an evolved concept of service design that resonates with patients' needs. As a result, providers are increasingly turning to patient-reported feedback to drive local improvement. This trend is indicative of progress in the field of patient experience: policy discourse has...
Since publication of To Err is Human: Building a Safer Health System,1 consideration of medical errors and injuries has broadened beyond hospital-based harms to patient experiences of harm in primary care.2 3 The National Patient Safety Foundation (NPSF)4 has concluded that progress towards a healthcare culture of safety depends on the establishment of a systems approach that extends beyond hospitals to care settings in the community and patients' homes, herein referred to as ambulatory care settings. Included in NPSF's recommendations for such an approach is partnering with patients and families at all levels of care. Less well articulated is how this partnering may be achieved in the settings highlighted by NPSF.
The objectives of this viewpoint are twofold. The first is to hypothesise pathways through which an empowered patient–family partnership may effectively advance healthcare safety and quality in ambulatory...
Since its inception, the patient safety movement has been obsessed with reporting systems; roughly 20% of the To Err Is Human report1 dealt with some aspect of reporting; similarly, about 10% of the articles in BMJ Quality & Safety (and its predecessors) mention ‘reporting’ in their title, abstract or keywords. This interest sprang from an unholy trinity—an infortuitous combination of the epidemiological bent of many health professionals interested in safety, the epistemological blinders that a medical education produces2 and a kind of ‘aviation envy’—a fascination with aviation safety as an exemplar which healthcare would do well to emulate.3 But, in an all-too-common pattern in patient safety, fundamental aspects of successful safety practices in other domains were misunderstood, misapplied, mistranslated or missed altogether as health professionals encountered work whose basic assumptions are far removed from the realism and positivism of biomedicine.2