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1.  Identifying early warning signs for diagnostic errors in primary care: a qualitative study 
BMJ Open  2012;2(5):e001539.
We investigate the mechanisms of diagnostic error in primary care consultations to detect warning signs for possible error. We aim to identify places in the diagnostic reasoning process associated with major risk indicators.
A qualitative study using semistructured interviews with open-ended questions.
A 2-month study in primary care conducted in Oxfordshire, UK.
We approached about 25 experienced general practitioners by email or word of mouth, 15 volunteered for the interviews and were available at a convenient time.
Interview transcripts provided 45 cases of error. Three researchers searched these independently for underlying themes in relation to our conceptual framework.
Outcome measures
Locating steps in the diagnostic reasoning process associated with major risk of error and detecting warning signs that can alert clinicians to increased risk of error.
Initiation and closure of the cognitive process are most exposed to risk of error. Cognitive biases developed early in the process lead to errors at the end. These warning signs can be used to alert clinicians to the increased risk of diagnostic error. Ignoring red flags or critical cues was related to processes being biased through the initial frame, but equally well, it could be explained by knowledge gaps.
Cognitive biases developed at the initial framing of the problem relate to errors at the end of the process. We refer to these biases as warning signs that can alert clinicians to the increased risk of diagnostic error. We conclude that lack of knowledge is likely to be an important factor in diagnostic error. Reducing diagnostic errors in primary care should focus on early and systematic recognition of errors including near misses, and a continuing professional development environment that promotes reflection in action to highlight possible causes of process bias and of knowledge gaps.
PMCID: PMC3467597  PMID: 22983786
Education & Training (see Medical Education & Training); Primary Care; Qualitative Research; Clinical reasoning; Clinical decision making
2.  Clinical decision making in a high-risk primary care environment: a qualitative study in the UK 
BMJ Open  2012;2(1):e000414.
Examine clinical reasoning and decision making in an out of hours (OOH) primary care setting to gain insights into how general practitioners (GPs) make clinical decisions and manage risk in this environment.
Semi-structured interviews using open-ended questions.
A 2-month qualitative interview study conducted in Oxfordshire, UK.
21 GPs working in OOH primary care.
The most powerful themes to emerge related to dealing with urgent potentially high-risk cases, keeping patients safe and responding to their needs, while trying to keep patients out of hospital and the concept of ‘fire fighting’. There were a number of well-defined characteristics that GPs reported making presentations easy or difficult to deal with. Severely ill patients were straightforward, while the older people, with complex multisystem diseases, were often difficult. GPs stopped collecting clinical information and came to clinical decisions when high-risk disease and severe illness requiring hospital attention has been excluded; they had responded directly to the patient's needs and there was a reliable safety net in place. Learning points that GPs identified as important for trainees in the OOH setting included the importance of developing rapport in spite of time pressures, learning to deal with uncertainty and learning about common presentations with a focus on critical cues to exclude severe illness.
The findings support suggestions that improvements in primary care OOH could be achieved by including automated and regular timely feedback system for GPs and individual peer and expert clinician support for GPs with regular meetings to discuss recent cases. In addition, trainee support and mentoring to focus on clinical skills, knowledge and risk management issues specific to OOH is currently required. Investigating the stopping rules used for diagnostic closure may provide new insights into the root causes of clinical error in such a high-risk setting.
Article summary
Article focus
Clinical reasoning and decision making in an out of hours (OOH) primary care setting.
The aim is to gain insights into how general practitioners (GPs) make clinical decisions and manage risk in this environment.
Implications for system changes and training.
Key messages
Clinical decision making in OOH is dominated by rule-out strategies for severe illness or potentially high-risk diseases.
GPs use three main criteria to determine diagnostic closure: global wellness with rule-outs, responded to patient needs, presence of a reliable safety net.
Improvements to clinical decision making could be achieved by providing routine feedback to clinical staff working in OOH, building in systems to support reflection on clinical cases and more tailored GP training.
Strengths and limitations of this study
The design of the study is based on a strong theoretical framework provided by the dual theory of cognition.
Face validity through using recently seen cases.
Limitations relate primarily to sampling, participants consisting of self-selected individuals.
PMCID: PMC3330259  PMID: 22318661

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