Presentation
PS17 - What is going on at the time of diagnosis? A prospective descriptive analysis of the activities and interactions that are competing for an emergency department doctor’s attention.
DescriptionIntroduction:
Diagnostic error (DE) is a failure to present a patient with a timely explanation of their symptoms, and is a leading source of preventable harm, in-hospital mortality, morbidity, and physician malpractice claims. While DE has been the focus of patient safety improvement work for over 15 years, there have been no significant improvements. The purpose of this study was to characterize the sociotechnical context in which the process of diagnosis is situated using naturalistic observations. To our knowledge, there is no literature regarding the characterization of tasks conducted during the diagnostic process in the pediatric emergency department. This understanding will help to fill the gap and serve as the foundation to better inform meaningful solutions. Guided by sociotechnical lens of SEIPS 2.0 (System Engineering Initiative for Patient Safety), we used observations to captured data regarding the tasks and interactions with people, tools, technologies, and other aspects of the environment that play a role an attending physician’s diagnostic process in the pediatric emergency room.
Methods:
This is a prospective observational pilot study utilizing a novel data collection tool (DCT) in RedCap that we iteratively piloted and tested for this study. The unique aspect of the DCT was it used a SEIPS framework to capture the tools/technology, people, and other environmental factors to quantify the interactions ongoing during a physician’s diagnostic work. Participants were pediatric emergency medicine attending physicians observed in four-hour shifts by two trained observers (medical students). Each observer shadowed a single physician as they went about their work captured their activities and interactions using an iPad.
Results:
Observations took place across day, night, and weekend shifts, over 2 months (July – August 2023) and include 21 unique attending physicians. Observers captured a total of 125 diagnostic encounters in 160 hours of observations, across 40 shifts. We identified 87 observation periods that captured physicians’ activities for a patient’s first 60 minutes upon arrival. The average number of activities that the attending conducted in the first hour of the diagnostic process was 48 (SD = 17). Of all activities, 40% (1,972/4,949) used technology The top three activities with the longest durations included: discussions with another provider (9.22 minutes), counseling/discussing next steps with patient/family (8.88 minutes) and staffing a patient (8.78 minutes) – each taking up approximately 12% of the time. Non-clinical activities were the 4th highest duration at 8.15 minutes (11%). Top patient/family interaction included: counseling or discussing next steps with patient/family (6.55 minutes), performing physical exam (2.92 minutes), and taking history (2.98 minutes). The proportion of time spent in the patient room, arena and unknown areas was 31%, 66% and 2%, respectively. The mean time spent in the patient room was 13.6 minutes versus time spent doing work for that patient outside the room was 28.6 minutes.
Conclusion:
Our findings represent the multitude of activities and while the DE literature has described a multidisciplinary team in performing a diagnosis, the nature and amount of communication has not been described. We observed that 40% of the tasks rely on tools and technologies, which to our knowledge has never been characterized. We are also able to descriptively say that the physician spends more time caring for the patient outside the room than in the room. In the literature to date, there is no such characterization of physician diagnostic work in context. These results demonstrate that the diagnostic process is incredibly complex and further, the physician does not have protected time for each patient but instead is conducting many competing tasks and interactions requiring task switching and divided attention. To understand the nature of physician work, it is critical to consider all aspects of the sociotechnical system.
Resources:
Holden RJ, Carayon P, Gurses AP, Hoonakker P, Hundt AS, Ozok AA, Rivera-Rodriguez AJ. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics. 2013 Nov 1;56(11):1669-86.
Diagnostic error (DE) is a failure to present a patient with a timely explanation of their symptoms, and is a leading source of preventable harm, in-hospital mortality, morbidity, and physician malpractice claims. While DE has been the focus of patient safety improvement work for over 15 years, there have been no significant improvements. The purpose of this study was to characterize the sociotechnical context in which the process of diagnosis is situated using naturalistic observations. To our knowledge, there is no literature regarding the characterization of tasks conducted during the diagnostic process in the pediatric emergency department. This understanding will help to fill the gap and serve as the foundation to better inform meaningful solutions. Guided by sociotechnical lens of SEIPS 2.0 (System Engineering Initiative for Patient Safety), we used observations to captured data regarding the tasks and interactions with people, tools, technologies, and other aspects of the environment that play a role an attending physician’s diagnostic process in the pediatric emergency room.
Methods:
This is a prospective observational pilot study utilizing a novel data collection tool (DCT) in RedCap that we iteratively piloted and tested for this study. The unique aspect of the DCT was it used a SEIPS framework to capture the tools/technology, people, and other environmental factors to quantify the interactions ongoing during a physician’s diagnostic work. Participants were pediatric emergency medicine attending physicians observed in four-hour shifts by two trained observers (medical students). Each observer shadowed a single physician as they went about their work captured their activities and interactions using an iPad.
Results:
Observations took place across day, night, and weekend shifts, over 2 months (July – August 2023) and include 21 unique attending physicians. Observers captured a total of 125 diagnostic encounters in 160 hours of observations, across 40 shifts. We identified 87 observation periods that captured physicians’ activities for a patient’s first 60 minutes upon arrival. The average number of activities that the attending conducted in the first hour of the diagnostic process was 48 (SD = 17). Of all activities, 40% (1,972/4,949) used technology The top three activities with the longest durations included: discussions with another provider (9.22 minutes), counseling/discussing next steps with patient/family (8.88 minutes) and staffing a patient (8.78 minutes) – each taking up approximately 12% of the time. Non-clinical activities were the 4th highest duration at 8.15 minutes (11%). Top patient/family interaction included: counseling or discussing next steps with patient/family (6.55 minutes), performing physical exam (2.92 minutes), and taking history (2.98 minutes). The proportion of time spent in the patient room, arena and unknown areas was 31%, 66% and 2%, respectively. The mean time spent in the patient room was 13.6 minutes versus time spent doing work for that patient outside the room was 28.6 minutes.
Conclusion:
Our findings represent the multitude of activities and while the DE literature has described a multidisciplinary team in performing a diagnosis, the nature and amount of communication has not been described. We observed that 40% of the tasks rely on tools and technologies, which to our knowledge has never been characterized. We are also able to descriptively say that the physician spends more time caring for the patient outside the room than in the room. In the literature to date, there is no such characterization of physician diagnostic work in context. These results demonstrate that the diagnostic process is incredibly complex and further, the physician does not have protected time for each patient but instead is conducting many competing tasks and interactions requiring task switching and divided attention. To understand the nature of physician work, it is critical to consider all aspects of the sociotechnical system.
Resources:
Holden RJ, Carayon P, Gurses AP, Hoonakker P, Hundt AS, Ozok AA, Rivera-Rodriguez AJ. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics. 2013 Nov 1;56(11):1669-86.
Event Type
Poster Presentation
TimeMonday, March 254:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives