In Episode 32 we discussed cognitive error in diagnostic reasoning. On this episode, we take a look at systems pressures that increase the likelihood of medical error, crystallised by the recent prosecution of NHS paediatrician Dr Hadiza Bawa-Garba. Almost half of diagnostic errors are due to a combination of systems errors and individual cognitive error. Obvious systems effects come into play in understaffed acute care units; if a clinician is forced to see too many patients without enough time to make careful examinations or reasoned decisions, errors become more likely. The stepping stones of ordering, receiving and reviewing diagnostic tests and scans also allow much opportunity for error and delay. Guests on this episode discuss mechanisms to improve efficiencyObvious systems effects come into play in understaffed acute care units. If a clinician is forced to see too many patients without enough time to make careful examinations or reasoned decisions, errors become more likely. And of course, long hours and fatigue will only reduce cognitive capacity. Hospital systems also include the stepping stones of ordering, receiving and reviewing diagnostic tests and scans. Missteps and delays in this cascade contribute to a large proportion of diagnostic errors. Guests on this episode discuss mechanisms to improve efficiency.Another important step in improving health systems is capturing and reporting error rates accurately. If clinical error is wrapped in culture of blame and punishment, it will make such disclosure more difficult. This concern has been raised in response to the recent prosecution of U.K. National Health Service (NHS) paediatrician Dr Hadiza Bawa-Garba, who had her licence to practice medicine revoked for her role in the death of a young patient. Six-year old Jack Adcock died on a chaotic day in 2011 at the Leicester Royal Infirmary that involved delays in the diagnosis and treatment of his sepsis. Today’s episode examines how widespread systems errors contributed to such mistakes.Guests Professor Jeffrey Braithwaite FAIM, FACHSM, FAHMS, FFPH-RCP, FAcSS, Hon FRACMA (Australian Institute for Health Innovation, Macquarie University) Associate Professor Ian Scott FRACP (Director, Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, University of Queensland) Associate Professor David Heslop FRACGP (University of New South WalProduction Written and produced by Mic Cavazzini. Additional audio recording from James Milson and Jennifer Leake. Music courtesy of Kai Engel ('Memories'), Jahzarr ('Become Death'), Sergey Cheremisinov ('Now You Are Here') and Loch Lomond ('Violins and Tea'). Image courtesy of Max Pixel. The production manager was Anne Fredrickson. Editorial feedback for this episode was provided by RACP Fellows Paul Jauncey, Phillipa Wormald, Katrina Gibson, Rosalynn Pszczola, Andrea Knox, Philip Gaughwin, Rhiannon Mellor and Richard Doherty. Please visit the RACP website for a transcript embedded with citations. Fellows of the College can claim CPD credits for listening and additional reading. <

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