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Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators

Appendix A. SIDM Competencies To Improve Diagnosis and Suggested Questions for Debriefing Case Studies

Table of Contents

Competency	Suggested Questions
I. Individual Competency: Demonstrate clinical reasoning to arrive at a justifiable diagnosis (an explanation for a health-related condition)
I-1. Accurately and efficiently collect key clinical findings needed to inform diagnostic hypotheses.	What are the patient’s primary concerns and symptoms? What do you think is going on with this patient? Are your impressions consistent with those of the primary care provider/care team? If not, have you communicated your thoughts/questions to them? What findings lead to the team’s potential diagnoses?
I-2. Formulate, or contribute to, an accurate problem representation expressed in a concise summary statement that includes essential epidemiological, clinical, and psychosocial information.	How would you summarize the patient’s problem and your findings? What tools do you have to help you organize your thoughts/findings (e.g., SBAR)? How do your findings relate to other team members’?
I-3. Produce, or contribute to, a correctly prioritized, relevant differential diagnosis, including can’t-miss diagnoses.	How confident are you about the diagnosis for this patient? What else do you think could be going on with this patient? Which current or new findings would need immediate attention and why?
I-4. Explain and justify the prioritization of the differential diagnosis by comparing and contrasting the patient’s findings and test results with accurate knowledge about prototypical or characteristic disease manifestations and atypical presentations, and considering pathophysiology, disease likelihood, and clinical experience.	What are some more common health problems that can cause these findings? What are some more atypical health problems? Have you identified findings or symptoms that do not fit the patient’s diagnosis? What further tests or monitoring might be helpful to understand what is really going on with the patient? What would you expect to see as the patient receives treatment for this diagnosis? Over what period of time?
I-5. Use decision support tools, including point-of-care resources, checklists, consultation, and second opinions to improve diagnostic accuracy and timeliness.	What tools or resources were used to come up with this diagnosis? What are some additional resources you and the team could use to ensure an accurate diagnosis? What team members can you consult with to discuss your findings or concerns?
I-6. Use reflection, surveillance, and critical thinking to improve diagnostic performance and mitigate detrimental cognitive bias throughout the clinical encounter.	Knowing what you know now, what additional questions would you ask to gather key information on this patient? What additional assessments would you perform? How might you include the patient and family in the surveillance process? What are some biases that might exist and affect decisions about this patient’s diagnosis?

Source: Society to Improve Diagnosis in Medicine. Competencies & Learning Objectives: Consensus Curriculum on Diagnosis. https://www.improvediagnosis.org/consensuscurriculum-competencies/. Accessed September 2, 2022.

Competency	Suggested Questions
T. Team-Based Competency: Partner effectively as part of an interprofessional diagnostic team. Communicate effectively and solicit information from all members of the team (including the patient and family) to create a shared mental model of a patient’s illness and the plan for diagnostic evaluation.
T-1. Engage and collaborate with patients and families, in accordance with their values and preferences when making a plan for diagnostic evaluation.	How well do you think the primary care provider/physician listened to and understood the patient’s concerns? How would you assess the patient and family’s knowledge of the diagnosis? What additional education or followup needs do you think this patient and family might have regarding their diagnosis or treatment plan? Whom do you need to collaborate with when making a plan for this patient? What would you tell patients or ancillary members of the care team to get them more involved in a culture of safety?
T-2. Collaborate with other healthcare professionals (including nurses, physicians, physician assistants, radiologists, laboratory professionals, pharmacists, social workers, physical therapists, medical librarians, and others) and communicate effectively throughout the diagnostic process. Acknowledge and challenge authority gradients, especially between clinicians and patients/families, constructively.	How would you communicate the patient’s problem and your findings to the diagnostic team? What tools could you use to help you communicate your findings? What are some of the communication modalities you have available to communicate your findings? Would you want to facilitate a second opinion or consult another nurse? Would you want to involve another provider or healthcare team member? If so, how would you message that to the team? What would you tell new nurses afraid to voice their concerns?
T-3. Apply effective strategies at transitions of care to facilitate accurate and sufficient information transfer about the diagnosis, including any pending workup and areas of uncertainty. Close the loop on test result communication and clarify expectations with the team for test result followup.	How would you tell the patient about their next steps? What resources would you recommend to the patient to learn more about their diagnosis? What communication tools or strategies can be used to ensure that the other team is receiving complete and accurate information when the patient transfers? What tools do you have to ensure that patient followup and any pending results are not forgotten?

Competency	Suggested Questions
S. System-Related Competency: Identify and understand the systems factors that facilitate and contribute to timely, accurate diagnoses and error avoidance.
S-1. Discuss how human factors contribute to diagnostic safety and error by identifying how the work environment influences human performance. Take steps to mitigate common systems factors that detract from diagnostic quality and safety.	Why do you think this patient was (or could get) misdiagnosed? Who is responsible for ensuring that the diagnosis, results, or next steps are communicated to the patient? What systems are in place here to ensure that appropriate followup has occurred? What are some reasons an error could occur related to your work environment? Have you and your team been able to speak up if you have concerns related to this patient diagnosis or situation? If not, what are your next steps to ensure they are heard?
S-2. Advance a culture of diagnostic safety that encourages open dialogue and continuous learning from analysis and discussion of excellent diagnostic performance, near-misses, and errors.	How could your organization share the near-misses, errors, and excellent diagnostic performance from a clinical situation with one another? What is the value in debriefing a clinical scenario to the organization? Who should attend a debriefing of a clinical situation?
S-3. Disclose diagnostic errors and missed opportunities transparently and in a timely manner to patients, families, team members, supervisors, and appropriate quality and risk management staff.	What problems or gaps do we have at our institution to prevent diagnostic errors like this from occurring? How and to whom would you report this error [or missed opportunity]? How would you respond to a difficult colleague who disagrees with transparency and disclosure? What resources do you have to help you if you are feeling fearful or uncomfortable with decisions being made by anyone on the care team?

Page last reviewed September 2022

Page originally created September 2022

Internet Citation: Appendix A. SIDM Competencies To Improve Diagnosis and Suggested Questions for Debriefing Case Studies . Content last reviewed September 2022. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety-apa.html