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Background The Quality and Patient Safety Division (QPSD) has received a number of Safety and Quality Review (SQR) reports of patient events associated with delayed or missed diagnosis. This Advisory is issued to support health care facilities in the review and development of their approaches to the diagnostic process in the inpatient and emergency department (ED) settings and the overall reduction of diagnostic errors. While some references are provided, this Advisory does not include a comprehensive review of the literature; nor is it intended to provide specific recommendations for evidence-based practice. Publication of this Advisory does not constitute an endorsement by the Board of any studies or practices described in the Advisory and none should be inferred. Overview Clinical diagnostic errors can occur in a variety of ways: a missed diagnosis, treating a patient for the wrong diagnosis, or the failure to recognize and address conflicting patient data. Diagnostic errors are common, frequently preventable and often underreported. There are an estimated 40-80,000 deaths nationally per year from diagnostic error. 1 In a recent survey commissioned by the Betsy Lehman Center, 23% of surveyed adults in Massachusetts reported experiencing a diagnostic error in the last 5 years, with 75% of these errors occurring during treatment at a hospital. 2 Specialty error rates range from 2-3% in radiology and pathology to 10-20% for internal medicine. 3,4 Diagnostic errors can be the result of the confluence of insufficient data, communication lapses, variable disease presentations, a variety of provider biases and heuristics (mental shortcuts) and other sources of cognitive error. This advisory will focus on diagnostic processes in the inpatient and emergency department settings.

Although a definitive treatment progression for treating CR has not been developed a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as AROM, while decreasing levels of pain and disability. High quality RCTs featuring control groups are necessary to establish clear and effective protocols in the treatment of CR.

BackgroundCoronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome-coronavirus-2. Consensus suggestions can standardise care, thereby improving outcomes and facilitating future research.MethodsAn International Task Force was composed and agreement regarding courses of action was measured using the Convergence of Opinion on Recommendations and Evidence (CORE) process. 70% agreement was necessary to make a consensus suggestion.ResultsThe Task Force made consensus suggestions to treat patients with acute COVID-19 pneumonia with remdesivir and dexamethasone but suggested against hydroxychloroquine except in the context of a clinical trial; these are revisions of prior suggestions resulting from the interim publication of several randomised trials. It also suggested that COVID-19 patients with a venous thromboembolic event be treated with therapeutic anticoagulant therapy for 3 months. The Task Force was unable to reach sufficient agreement to yield consensus suggestions for the post-hospital care of COVID-19 survivors. The Task Force fell one vote shy of suggesting routine screening for depression, anxiety and post-traumatic stress disorder.ConclusionsThe Task Force addressed questions related to pharmacotherapy in patients with COVID-19 and the post-hospital care of survivors, yielding several consensus suggestions. Management options for which there is insufficient agreement to formulate a suggestion represent research priorities.

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Critical thinking, the capacity to be deliberate about thinking, is increasingly the focus of undergraduate medical education, but is not commonly addressed in graduate medical education. Without critical thinking, physicians, and particularly residents, are prone to cognitive errors, which can lead to diagnostic errors, especially in a high-stakes environment such as the intensive care unit. Although challenging, critical thinking skills can be taught. At this time, there is a paucity of data to support an educational gold standard for teaching critical thinking, but we believe that five strategies, routed in cognitive theory and our personal teaching experiences, provide an effective framework to teach critical thinking in the intensive care unit. The five strategies are: make the thinking process explicit by helping learners understand that the brain uses two cognitive processes: type 1, an intuitive pattern-recognizing process, and type 2, an analytic process; discuss cognitive biases, such as premature closure, and teach residents to minimize biases by expressing uncertainty and keeping differentials broad; model and teach inductive reasoning by utilizing concept and mechanism maps and explicitly teach how this reasoning differs from the more commonly used hypothetico-deductive reasoning; use questions to stimulate critical thinking: "how" or "why" questions can be used to coach trainees and to uncover their thought processes; and assess and provide feedback on learner's critical thinking. We believe these five strategies provide practical approaches for teaching critical thinking in the intensive care unit.

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