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
