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  • 1.  Patient Safety Awareness Week: Focusing on Diagnosis

    Posted 03-16-2022 23:44

    Dear friends and colleagues:  

    Once again, happy Patient Safety Awareness Week !   First, a reminder of the AHRQ twitter-chat on diagnosis tomorrow (Thursday, April 17) at Noon Eastern:   #AHRQchat

    And.... This is the perfect time to bring to attention

    1)      The outstanding set of diagnosis-related issue briefs from AHRQ – the list is included below, AND

    2)      The ongoing series of feature articles in JAMA sponsored by the Moore Foundation supporting the concept of diagnostic excellence.  Nine articles have been published to date (attached) and more are forthcoming.

    AHRQ Issue Briefs on Diagnosis

    Journal Articles


    Best regards to all,


    Mark L Graber MD FACP

    Founder and President Emeritus, Society to Improve Diagnosis in Medicine

    Professor Emeritus, Stony Brook University, NY

    Cell:  919 667-8585




  • 2.  RE: Patient Safety Awareness Week: Focusing on Diagnosis

    Posted 03-17-2022 09:43
    In addition to Marks great list, I encourage you to also take a look at other AHRQ resources developed to support diagnostic safety.   Earlier this week The Agency for Healthcare Research and Quality (AHRQ) has released a new course to raise diagnostic safety awareness and help to improve communication and teamwork among all members of the care team. TeamSTEPPS® for Diagnosis Improvement is composed of seven PowerPoint modules that are customizable to the needs of the local team and course facilitator. A facilitator's guide, participant workbook and Team Assessment Tool are also included to help the course facilitator plan and implement a customized plan to train staff in teamwork and communication and improve the diagnostic process. The TeamSTEPPS® for Diagnostic Improvement Course can be downloaded at https://tinyurl.com/w3726xa2.  

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  • 3.  RE: Patient Safety Awareness Week: Focusing on Diagnosis

    Posted 03-22-2022 16:48
    Thank you for sharing this new content.
    I was very excited to review the materials but my excitement turned to dismay when I viewed the case study.

    I am a nurse and advocate for nurses being active participants in the team diagnostic process. The case study does include a nurse. The nurses contribution is that the patient told them they had new pets and this might be a factor to include in the diagnostic process. This information is secondary patient information and does not reflect nursing scope of practice and expertise. 

    If you read the case study please notice the difference in the contribution of the pharmacist. Also note the similarities in the receptionist contribution and the nurses contribution. 

    My dismay turned to anger and then discouragement. I view this as a "team" problem - AHRQ writers did not understand and/or value the nurses role. How do we correct this?


    Marge Benham-Hutchins RN, PhD
    Associate Professor
    Chair, Department of Biobehavioral Health Science
    College of Nursing and Health Sciences
    Texas A&M University Corpus Christi

  • 4.  RE: Patient Safety Awareness Week: Focusing on Diagnosis

    Posted 03-23-2022 14:51

    Thank you Dr Benham-Hutchins for your comments and support of the AHRQ course TeamSTEPPS to Improve Diagnosis. 
    I led a team of diverse subject matter experts who developed the course under contract to AHRQ.   The team included many subject matter experts, including nurses, physicians and patients and was field tested across the country by many teams led by nurse/physician dyads.  
    The nursing example you cite is a "hypothetical" stand-alone thought. Neither it nor the other examples in the slide refer to the Mr. Kane case

     The example surfaces in Module 7, Putting it All Together, when we remind the learners that It is important for everyone within the diagnostic process to understand their responsibilities as part of the diagnostic team and contribute to improving diagnosis.

    In hindsight, the thoughts attributed to the nurse could have been more clinically oriented, but pets as a potential source of asthma exacerbation is also an important and appropriate consideration during diagnosis and treatment. 

    Thanks again for sharing your perspectives.  Feel free to reach out to me directly if you have other insights. 

    with gratitude,

    Christine Goeschel ScD RN
    Assistant Vice President
    MedStar Institute for Quality & Safety (MIQS)
    Professor of Medicine, Georgetown University

  • 5.  RE: Patient Safety Awareness Week: Focusing on Diagnosis

    Posted 03-23-2022 19:41
    Thank you for acknowledging my concern and sharing the specific information I was referring to in my post. My dismay was the use of this example for the crucial "Putting it all together" content. The contrast between the front desk personnel referring to slurred speech (a clinical observation), the pharmacist's professional input, and the nurse anecdotal contribution about pets is what bothered me. I agree that a clinical and professionally focused contribution by the nurse would improve this hypothetical scenario. Unfortunately, this type of scenario - while in some ways appearing harmless - adds to stereotypes and misconceptions about the nursing role. 

    I would love to hear from you and the group on how we can improve understanding of the role of the nurse as an active participant on diagnostic and interdisciplinary care teams.

    Thank you, 

    Marge Benham-Hutchins RN, PhD
    Associate Professor
    Chair, Department of Biobehavioral Health Science
    College of Nursing and Health Sciences
    Texas A&M University Corpus Christi