Storytelling is a powerful form of communication and can serve as a catalyst for safety and healthcare change.41,42 Patient cases based on real-life experiences can be incorporated into any chosen learning strategy and can enhance student learning by imparting relevance, aiding connections between theory and practice, and improving clinical performance, attitudes, and teamwork.43-46
Patient cases that specifically illustrate the nurse’s role in the diagnostic process can be used to introduce diagnostic concepts, facilitate conversation about nurses’ roles in the diagnostic process, and identify barriers and opportunities for improving diagnostic safety. Table 2 presents suggested steps for presenting and debriefing patient cases to enhance nurses’ learning about diagnostic safety.
Table 2. Suggested Steps To Use Patient Cases for Diagnostic Safety Learning
|Presenting Case Studies
|Debriefing and Next Steps
Several sources can be used to identify cases that illustrate nurses’ role in the diagnostic process, including:
- Vignettes, such as the examples presented at the end of this section or on the SIDM website48 and AHRQ’s Patient Safety Network,49 can be used to elucidate nurses’ everyday contributions to the diagnostic process.
- Individual institutions’ data sources, such as patient safety event reporting, patient reports, and clinician reports, can be used to identify additional diagnostic case studies.
- The Measure Dx resource,50 a guide developed by AHRQ and partners, provides guidance for organizations and healthcare team members to detect, analyze, and learn from diagnostic safety events in their day-to-day operations.
Any safety events or “good catches” identified from these data sources can be used as diagnostic safety case studies for educating nursing and interprofessional teams.
Nurse educators can use patient cases to facilitate discussion and promote problem solving about diagnostic safety issues. To foster reflective thinking and reinforce key learning concepts, educators can use debriefing with “good judgment,” acknowledging that their view may not be the only one and sharing their expertise only to promote learners’ self-reflection and facilitate group discussion.47,51
Appendix A presents a list of questions designed to promote discussion and critical thinking about diagnostic safety. These questions are organized and aligned with the 12 key competencies for high-quality diagnosis that were reviewed and refined by an interprofessional consensus group convened by SIDM in 2019.52
Patient Safety Vignettes
Vignette 1: Behavioral Changes in an Elderly Patient
A certified nurse assistant in an assisted living facility observes an elderly male patient becoming increasingly agitated and reports this assessment to the patient’s assigned nurse. The patient has a medical history significant for dementia and prostate cancer. The nurse obtains vital signs and performs a mental status exam, noting a change from the patient’s baseline. The nurse assesses the patient’s shift intake and output, noting that the patient has not voided in over 8 hours. She also performs a bladder scan to assess for urine retention. She contacts the physician, notifies her of the mental status change and decreased urine output, brings up the possibility that these changes may be due to a urinary tract infection, and clarifies the next steps and plan of care.
Vignette 2: A “Frequent Flier” in the Emergency Department
A patient presents to the emergency department with loss of consciousness. The admitting physician describes the patient in his notes as a “frequent flier who has presented to the emergency department today and several times throughout the year with alcohol intoxication.” In completing the patient’s admission data, the nurse learns from the patient’s wife that the patient has been unemployed and had been drinking to cope with his stress but has recently expressed “giving up on finding a job and not wanting to be here anymore.” The nurse asks the patient’s wife if she has ever asked her husband additional questions about suicide. She contacts the physician, notifies him of the suicidal ideation, and requests further evaluation and precautions for the patient when he awakens.
Vignette 3: Split Medical Care
A nurse is completing intake information for an older female patient complaining of lightheadedness with a past medical history of congestive heart failure, hypertension, hyperlipidemia, and gout in an urgent care clinic. The nurse learns that the patient splits her time visiting her two children and that her medical care is managed in two different states. The nurse contacts both children separately and asks for a list of the patient’s current medications, performs a medication reconciliation, and discovers that the patient is receiving several similar antihypertensive medications.