The next organizational challenge: finding and addressing diagnostic error.

Background: Although health care organizations (HCOs) are intensely focused on improving the safety of health care, efforts to date have almost exclusively targeted treatment-related issues. The literature confirms that the approaches HCOs use to identify adverse medical events are not effective in finding diagnostic errors, so the initial challenge is to identify cases of diagnostic error. WHY HEALTH CARE ORGANIZATIONS NEED TO GET INVOLVED: HCOs are preoccupied with many quality- and safety-related operational and clinical issues, including performance measures.

A Qualitative Analysis of Physician Perspectives on Missed and Delayed Outpatient Diagnosis: The Focus on System-Related Factors.

Background: Delayed and missed diagnoses lead to significant patient harm. Because physician actions are fundamental to the outpatient diagnostic process, a study was conducted to explore physician perspectives on diagnosis.

Methods: As part of a quality improvement initiative, an integrated health system conducted six physician focus groups in 2004 and 2005.

Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians.

Background: Although misdiagnosis in the outpatient setting leads to significant patient harm and wasted resources, it is not well studied. The authors surveyed primary care physicians (PCPs) about barriers to timely diagnosis in the outpatient setting and assessed their perceptions of diagnostic difficulty.

Methods: Surveys of PCPs practicing in an integrated health system across 10 geographically dispersed states in 2005.

Increasing the completion of the durable power of attorney for health care. A randomized, controlled trial.

Objective: Wider use of written advance directives may prevent many ethical dilemmas about life-sustaining interventions for patients who have lost decision-making capacity. We investigated whether a simple educational intervention increased patient completion of the durable power of attorney for health care.

Design: A randomized, controlled trial.

Fluconazole-resistant Candida in AIDS patients. Report of two cases.

Oropharyngeal candidiasis develops in up to 95% of patients with acquired immunodeficiency syndrome. Oral fluconazole is frequently prescribed for persons who are human immunodeficiency virus-seropositive as initial or suppressive therapy for oropharyngeal and esophageal candidiasis or as suppressive therapy for cryptococcal meningitis. We report two cases of oropharyngeal candidiasis, caused by Candida albicans, which developed in two patients with acquired immunodeficiency syndrome who had taken fluconazole for extended periods.

Do patients want to participate in medical decision making?

Although shared decision making by patients and clinicians has been advocated, little is known about the degree of participation in decision making that patients actually prefer or about clinicians' appreciation of these preferences. We administered questionnaires about three aspects of decision making to 210 hypertensive outpatients and to their 50 clinicians, who represented three types of medical practices. We found that 41% of patients preferred more information about hypertension; clinicians underestimated patient preferences for discussion about therapy in 29% of cases and overestimated 11% (k = .

Influence of dietary sodium on renin activity and arterial pressure during anesthesia.

The effect of pentobarbital anesthesia on plasma renin activity (PRA) and mean arterial pressure (MAP) was studied in chronically catheterized dogs maintained on normal or low-sodium intake. Within 1 min of administration, pentobarbital caused a rapid fall in MAP which was followed by a restoration of MAP toward control within 5 min. Thirty minutes after induction of anesthesia, PRA was unchanged in sodium-replete dogs and elevated two-fold in sodium-depleted dogs.