Social Sciences 🗑 Flashcards
Most diagnostic errors involve what?
Cognitive bias (not lack of knowledge)
Common cognitive errors:
Availability
Allowing recently seen or memorable Dx to sway current Dx
Common cognitive errors:
Anchoring
Fixating on initial impression of what was thought to be Dx
Common cognitive errors:
Framing
Dx approach is influenced by context. Like opioid withdrawal in IVDU, even if the Dx was bowel Obs
Common cognitive errors:
Confirmation
Emphasising evidence to support thought Dx. Related to anchoring
What is metacognition
Where a doctor understands flaws in their cognitive patterns and bias.
If a patient is knocking at heavens door and needs decisions made. No advance directive. What is your priority
Find surrogate decision maker. And get families perspective in what they think patient would have wanted. Not what you think is best for patient.
If family cannot come to a consensus on what patient would have wanted…. What to do
Ultimately chief decision maker calls the shots, usually the spouse, then the parents.
Disability insurance. What is it
Doctor can signs for a specific period of time, to allow patient money to be off work. Must specify specific for how long he cannot work, severity, limitations, limitations to job specifically, the illness details etc. Must be proper and legit.
If someone has issue and cannot work for disability reasons. If they don’t meet the criteria to have disability insurance,,,, can do what
Doctors can certify patient for limited time off
Patient wanting recommendations on complimentary/alternative medicine
Doctor should consult with or direct patient to reputable third party. For Eg. Supplements for OA. Some brands are pure and others are full of crap. So these independent organisation can help with this. Don’t stick to conventional and be dismissive
Patient is on therapy that the doctor has never heard of before (random herbal ting or hormone). Insists to keep taking it. Some ways the doctor can approach this
Be open and understanding. Acknowledge the patients motivations. Mom judgmental. Schedule regular follow-ups to monitor any adverse effects. Develope open communication. Don’t alternate patients by saying how it’s not evidence based
Who is eligible for hospice care
Palliative patients. Cannot be on curative therapy
Quality improvement mode:
Lean
Identification of waste in a system, and streamlining. For example identify patients have two appointments on two days, and making them on one day, so they can save on transport
Quality improvement:
Model for improvement
Like the PDSA cycle. So piloting a new thing, then reassessing and refining, then test again.
Quality improvement
Six sigma
Identifying issues in a system, then systematically eliminating them with statistical goals . So maybe finding that quite a few patients have wrong site surgery, so putting measures in place to make it <0.00001% likely to happen again
Examples of the Swiss cheese model
Anything that puts extra barriers to prevent the mistake from happening. So double checks, hard stops etc.
SPIKES
Setting
Perception
Invitation
Knowledge
Empathy
Dr has bad news to share with the patient. Patient wants to defer until spouse is with them in a couple of days
As long as no imminent danger, this is ok
Who can get home hospice care
Normal hospice requirement, roughly less than 6mo to live, and has forgone curative Tx. Family available at home. Inpatient if patient and family choose, or if cannot do at homr
Parents refuse life saving Tx for their child
Get court order for the Tx. If emergency, just give Tx
Main ways to prevent readmission, in simple terms
Communication and followup. So the best intervention will always be to arrange telephone chats with the patient or little appointments in the outpatient
Exceptions for informed consent for infant from guardian
Emergency
Emancipated child: parent, military, financially independent, high school graduate, married. Homeless
Certain medical care: STD, substance abuse, contraception and pregnancy care
Puncture wound due to rusty nail. Parents don’t want to give Ig or Vx in unvx’d kid.
Give it anyway. Counts as an emergency. Whereas routine Vx isn’t an emergency
If parents are divorced. Do we need both or one to get consent.
One. Especially if it’s in the best interest of the patient
What is root cause analysis
Systematic process to identify all contributing factors leading to an undesired outcome
What is a fish bone diagram
Used in root cause analysis, it’s where spines are multiple categories of causes of an issue. And the scales of each spine is the specific cause within a category. Head is the issue. For example an issue can be misdiagnosis. The spines could be clerical error, doctor error. Within the spine of doctor error, the scales could be doctor bias, rushed appointments, quality of doctor.
Some ways to minimise errors when transferring care
Implement standardized signout communication (eg, checklists or mnemonics)
• Avoid vague instructions (eg, “follow-up x-ray”); communicate specific action plans
= like specifics on when to give K, rather than monitor for K
• Conduct signout communication in quiet environment
• Add redundancy (eg, separately documenting cross-coverage events in addition to verbal signout communication)
• Ensure accuracy of information in written signout
What is redundancy generally
Doing something more than once, or in more than one way. So doing handover verbally and having olive to write handover notes separately. This sort of cross covers you and reduced omission of certain things
What is psychology safety
Where the team believes it’s ok to speak up against something, and they won’t be punished or humiliated.
Recall whole scenario where patient is awaiting results for likely CA. Wants results when they come back from a holiday instead,,,,, what do we do
Respect that (as long as it won’t make difference to the actual Tx if they need it)
Preparations for CIC and PICC insertion
• Hand hygiene (prior to use of gloves)
• Full barrier precautions (eg, mask, sterile gloves, gown, drape)
• Preparation of skin with chlorhexidine solution
• Procedure performed by experienced provider
Location of blood catheters to decrease infection
Use of PICCs and tunneled catheters
• For CVCs, use of subclavian and internal jugular vein sites over femoral vein
Blood Catheter duration to decrease infx
• Limit duration (eg, <6 days) for CVCs
• Prompt removal of catheter when no longer needed
• Avoid routine replacement of CVCs
Need to sort next of kin stuff/surrogate decision maker and patient doesn’t want family to know of Dx
Tricky, but should arrange another next of kin for the patient (since the default surrogate decision maker would be family)
Patient with meningococcal meningitis. Refuses to stay and have Tx
Needs isolation and inpatient Tx agains their will, no time for court order. Threat to society
Mx of agitated patient
Maintain 2 arms length. Avoid eyes contact. Door open and dr closer to exit. Verbal deescalation (calm voice, basic needs like food and drink, tell patient won’t be harmed, offer choices). Restraint and anti psych if imminent violence
Best ‘human factors engineering strategies’ name three. Then two others which are good. Then a meh one
Forcing functions (eg. Each anaesthesia tube fits only one socket)
Computerised automation (eg. HR and BP recorded by automated machine)
Environment/psychical layout (eg. Look alike drugs are stocked in different locations)
Also good: standardisation across hospitals, human machine redundancy (repetitive steps that confirm the correct action)
Double checks and reminders are meh. Visual cues are meh.
Healthcare value is defined as what
Ratio of quality to cost
Doctor wants to report findings of systematic problems in healthcare quality in hospital. To best to do this
Open communication (not anonymous) with relevant stakeholder, empathises charged goals and coordination. Don’t report to accreditation board unless serious issues arise
How to respond to a schizo patient who has hallucinations
Empathise without reinforcing or challenging it. Don’t say that it’s in their head (they don’t have insight). Can acknowledge it, but don’t say you hear it too
How to decrease med overuse when a patient is wanting a specific Invx
Do thorough examination and explain specifically what you are doing. Will convince them you are serious and not neglecting. Also address concerns
When someone asks a question but you are doing something. Best way to reduce errors
Minimise multitasking (don’t do two tasks together)
Minimise task switching (complete current task, then address person question)
Obvs best to work in distraction free zone
What does it mean to use neutral terminology when discussing DNR
Don’t frame it like: keep you from dying, help you live longer (patient finds it hard to accept)
Don’t frame it like: tubes, machines, pushing chest (hard for patient to accept)
Cross cultural care. How to make it better
Caring for many cultures. Patient centered, culuturally sensitive (understand now social cultural background influences health decisions). Enhanced communication (interpreter, consider how each culture likes to be talked to).
Avoid just proving information about some cultures. This isn’t so personal, and can increase stereotypes
Stages of change
Patient decides to change. What to do
Preparation
Encourage small steps and reinforce positive outcomes
Stages of change
Patient sees the issues with behaviour but is ambivalent. What to do
Contemplation
Do pros and cons. Promote good behaviours
Stages of change
Patient is not even considering changing and doesn’t aknowledge the issue. What to do.
Precontemplation
Encourage patient to evaluate consequences, and educate on issue more
Stages of change
Patient is making change
Action
Promote self efficacy. Enlist social support etc.
Stages of change
Patient has integrated change into life…. What to do
Maintenance .
Focus on relapse prevention. Reinforce intrinsic rewards, develop relapse prevention strategy
Stages of change
Patient has incorporated change into sense of self
Identification
Praise changes
Sensitivity and specificity equations. And just tell me a bit about the denominators
TP/TP + FN
TN/TN + FP
denominators are based on actual disease. So sensitivity denominator is all patients who have disease, specificity is denominator is all patients who do not have disease
The equation for positive and negative predictive value. Tell me about the denominators
TP/TP + FP
TN/TN + FN
denominators are based on test results. So PPV denominator is all patients who have positive test, NO is denominator is all patients who were tested negative.
What is the false negative rate
One minus sensitivity
What is the false positive rate
One minus specificity
When lowering or raising Kossoff values for diagnostic tests. Sensitivity and what to go together. Specificity and what go together
Sensitivity follows negative predictive value. Specificity follows positive predictive value
Once a patient has test results, if they are ever talking about how to interpret. Are we gonna be talking about sensitivity/spec or predictive values
Predictive values
Attributable risk and ARR
AR: Risk in exposed - risk in unexposed
ARR: Risk in unexposed - risk in exposed
Number needed to treat
1/ARR
ARR: risk in unexposed - risk in exposed
How does disease prevalence affect out and odds ratio can predict/approximate risk ratio
Lower disease prevalence means the odds ratio close approximates the risk ratio
What is a prevelance Study
A cross-sectional study used to estimate prevalent
What are other names for cohort studies
Incident studies, longitudinal studies, prospective studies
is precision and reliability the same
Yes yea yes (remember our target)
Out of accuracy and (precision or reliability or reproducibility) which increases with sample size
Precision/reliability/reproducibility. They are all the same thing. 
Case controls versus cohorts. Which can examine many risk factors
Case controls
What is factorial design in RCT
Essentially just having many different variables. For example aspirin versus statin versus aspirin and statin versus placebo
When is an RCT unethical
If the treatment has unknown serious adverse outcome, if the treatment is in widespread use and represents the best option
Can a cohort measure odds ratio?
Yes
Is a selection bias possible in cohort
Not really, unless it’s retrospective cohort
The main aim of phase 3 clinical trial
Compare rinsed the gold standard treatment, impatience with the disease
Main aim of the phase 2 trial
Patients with disease, seeing efficacy and adverse reactions.
Main difference between phase 0 and phase 1 clinical trial
Phase 0 is in a limited number of healthy volunteers, just to study the pharmacokinetics in the human body. Phase one is healthy volunteers to establish safety profile
What is attrition bias
A unique type of selection bias. A proportion of patients in one group are lost to follow up, often leading to an overestimation of association
Confounder or effect modifier
Patients who are on ECMO are not significantly more likely to have seizure than those with conventional CPR. However when is stratified by age it’s found that patients above 65 years old have significantly higher risk
Age here is an affect modifier
And if the P value is less than 0.05, this means we have a less than 5% chance of what era
Type one
Since Paula is the probability that a study will find a statistically significant difference given those untruly there. How can we write that in an equation
One - beta (in other words or type two error)
Increase sample size does what power
Increases power
Capitation versus fee for service cs bundle payment
Capitation is a healthcare provider will receive a set amount of money for a time frame, regardless of how much it costs or even if healthcare is used. Fee for service is where the patient or insurer will pay for each individual service as it’s used. Bundle payment is in between, where you pay a set amount for a duration of hospital, regardless of the end cost
Who gets Medicare
Patience above 65, young patients with disability, dialysis patients
Medicare ABCD
Hey is Admissions, nursing et cetera. B is basic medical bills. See is a and B. D is drugs
End of life, hospice care is considered when
When the prognosis for the patient is less than six months or when life-prolonging treatment is no longer beneficial
In SPIKES, what is the first things you do (SPI)
Setting and insure private room, if they want any body there with them. Perception so before proceeding with delivering the news just ask what the patient thinks about that illness et cetera. Invite so how they want the information given to them
What is the whole person first or identity first for disabled people
Person with disability, it’s person first. Disabled person is identity first.
In hard of hearing patience what do you do before consultation
Ask about preferred mode of communication
General rule of thumb with disabled patience, it’s always ask. Don’t assume they can’t do things, rather ask if they require assistance.
Facttt
If a patient prefers to use family member as interpreter, what do we do
Accept it, but recording in chart
Recall measuring quality outcomes. Structural, process, outcome, balancing 
Structural: measuring specific physical equipment or facilities (how many new blood pressure cuffs do we have, how accurate was the ABG machine)
Process: assessing a specific function in the healthcare system as planned (how many patients underwent the dialysis at the correct time)
Outcome: average uraemic levels in dialysis patients.
Balancing: assessing impact on other systems. (Given that we implement a orthopaedic call system to the ED, how many surgeries are delayed on the surgical ward
What is an active error
An error at the level of the front line operator, causing immediate impact
What is a latent error
An indirect process, like an accident waiting to happen.
What is a never event
An error that should never happen, that is major
What is a near miss
Event that could have lied to him but did not. Usually an intervention led to its prevention (Dr recognising a mistake from a nurse
What is negligence
A failure to meet an expected standard of care, that may lead to direct home
What is a sentinel event
An error that end up causing serious harm or death
What is failure modes and effects analysis
Implemented before an error (unlike records). Is usually do to identify potential ways assistant might fail, and prioritises higher currents and impact ones first. And then you can build redundancies on that
Is a doctor under an obligation to care for any patient. Outside of an emergency setting
The doctor is under no obligation legally. Therefore if a patient wants an abortion and it’s against his moral standard, all he has to do is make sure there is adequate alternative choices for her
What is the difference between decision-making capacity and competence
Competence is something determined by the court. And may apply to one or many facets. Decision-making capacity is usually determined by the healthcare providers. They do not always go hand-in-hand
What is the presumption we make with suicidal patience and capacity
They lack capacity
When is psychiatric evaluation needed for capacity determination
If equivocal. If it’s black and white pretty clear, don’t need this evaluation
What to do if emergency treatment is needed, but we don’t have any informed consent. And immediate intervention is necessary to prevent serious harm or death
Do the treatment. One instance of weapon essence overweighs autonomy
If a patient has lost consciousness, and no family members around to provide consent for a procedure. (Not 100% immediate). Is a telephone consent from a family member valid
In this circumstance yes
Can a patient with psychiatric illness give consent?
Of course, as long as their decision-making capacity is intact
If a patient expressed repeatedly that they didn’t want a procedure performed. Then the patient end up losing consciousness, and requiring the surgery. What do you do
Don’t do procedure
 When is the only time the father has any legal right to provide informed consent on a pregnancy related procedure for his wife
If she loses capacity, and he is the surrogate decision maker
Read circumstance never competent person needs inform consent, but there’s no guardian present
Third-party designated by the court can make decisions in patients interest
As we know one parent is sufficient for consenting for the child. What is the caveat to this
The parent does have to have custody
When a minor seeking an abortion, obviously this is an exception to the parental consent required. What is usually the best option in an answer
To accept but encourage patient to discuss with family. Or explore why they don’t want to
As we know in emergency situations, refusal of life-saving treatment from a parent on a child can be overridden by the clinician there and then. What about if nonemergent situation, yet treatment is still really in the best interest
Dr should gauge parents, keep discussing with them. Ultimately this is when the court order can be looked into
If a parent refuses immunisations for the child, is this considered a serious enough threat to warrant a court order
No. The parent has the right to refuse. But other cases similar to this may warrant a court order. If emergency overall anyway
Is consent needed to stop therapy in brain death
No. Two doctors needed to diagnose, but that’s it
Circumstance where intervention warranted to help a child. Father consents, mother does not want to consent. The intervention is in the best interests of the child
Obviously consult with them first. But proceed with the management eventually
If there was no healthcare proxy. And no living will/Advance directive. Obviously you get the family to discuss and come with a shared agreement. If the family members disagree even after discussion, what can be done
Hospital ethics committee. Court referral is last resort
If a patient has full capacity and decides to withdraw life-sustaining treatment. Do we need psychiatric evaluation
No, only if it’s uncertain as to the capacity
What is clinician assisted suicide versus euthanasia. Which states allow these
Euthanasia is a doctor administering the lethal agent, with the intent to end life. Illegal everywhere
Play Mission assisted suicide is where the doctor prescribes the lethal agent, for the patient to self administer. This is allowed in Washington Oregon Vermont Colorado and California. Court order is allowed in Montana
What is futile treatment. And what circumstances can a doctor refuse to treat futile conditions
Essentially treatment isn’t working/worth it
If there is no evidence/rationale for the treatment. If the intervention has already failed. If Max intervention is currently failing. And if treatment won’t achieve the goals of care.
What to do in the situation that a family member urges a doctor not to tell a patient something
Explore why the family member doesn’t want something revealed. But ultimately the patient should be told
If a patient them self does not want a diagnosis disclosed, what do we do
Explore why, but ultimately if they don’t wanna be told we don’t have to tell them
What is the therapeutic privilege
Where are Dr Killan withhold information from a patient without them telling them to, in the rare case that it would harm the patient severely (severe anxiety, suicide et cetera). 
This does not include reporting errors
When is it legally necessary to override confidentiality
Infectious disease, child abuse, elder abuse, suicide, violent crime, human trafficking, automobile driving impairment
If an emergency is it okay to break Confidentiality, to get consent from a family member on the phone
Yes
Monetary compensation in Research
Just out of pocket expenses only really
If an incurable disease patient has enrolled in study only with the anticipation of cure… Is this okay
No
In Research, do we need child assent
Yes we need parental consent and child accent
If patient has the inability to provide consent for Research , where do we get consent from
The next of kin or the legally authorised rep
Best way to go about domestic abuse
Offer support, acknowledge courage. Assess current safety to the woman and any potential children. Introduce concept of emergency plan, encourage use of a community resource. If the patient consent you can report abuse to authorities
What are the essential elements to negligence suit
The clinician had a duty to the patient, derilication of the duty occurred. That was damage to the patient. The damage was due to the Dereilcation
What is the good Samaritan law
Just a law that protects those with basic first aid training, who are certified by healthcare organisation to intervene in emergency settings. Even if something is slightly wrong
In medical suits we don’t have the beyond a reasonable doubt. What do we have
More likely than not. I.e. preponderance of the evidence
What is malpractice
Injury or permanent harm to a patient as a result of negligence
What is the approaches you should take if one of your colleagues is not fit to practice
Report to peer review body at the hospital (medical director for example) or if you don’t have hospital privilege to the local state medical board. If the patient safety is it immediate threat report directly to state licensing board
 Can you accept a gift from a drug company worth more than $10, or 100 cumulatively
No
