THE THINK STUDY: HIGH-FIDELITY SIMULATION TO PROMOTE THE USE OF A DIAGNOSTIC TIME-OUT AND A DIAGNOSTIC CHECKLIST IN PEDIATRIC PRACTICE

Background: Checklists have been useful in improving safety and reducing error in many arenas. Recent literature suggests that a diagnostic time-out and a diagnostic checklist may reduce diagnostic error. High fidelity simulation has been used to teach critical thinking skills and cognitive forcing strategies.  I hypothesize that by educating learners on diagnostic error, teaching them to take a diagnostic time out, use a diagnostic checklist (a novel mnemonic“Investigators THINK”) and practice it in a simulated setting, learners will be aware of when to question a diagnosis and apply the novel mnemonic to prevent cognitive errors and improve diagnostic accuracy.

Methods:  A pilot session with 15 interns and third year medical students was done in a limited one hour teaching session.  The format had three components: a case-based discussion illustrating premature closure of diagnosis, didactic session of diagnostic errors, and a high fidelity simulated scenario.  The didactic session also introduced the concept of a diagnostic time out and a diagnostic checklist, a novel mnemonic, “Investigators THINK” developed from John Murtagh’s chapter, “A Safe Diagnostic Strategy”.  Participants were given a cognitive aid for a diagnostic timeout and use the checklist “Investigators THINK”.  Four of 15 participants completed all components of the pilot which had a pre-experimental one group pre and post-test design.

Results: Evaluative measures included surveys before and after the session and quantitative measures of the participants’ use of the checklist and his/her diagnostic accuracy.  The 4 participants who completed all components demonstrated a trend toward an increase in ability to describe situations that predispose clinicians to making a diagnostic error (p=0.08) and describe common errors in arriving at a clinical diagnosis (p=0.09).  The participants did not achieve diagnostic accuracy, but initially used the Investigators THINK mnemonic to expand their differential diagnosis in the scenario. Participants gave qualitative feedback in the debriefing and post-surveys, and they reported session time was short.

Conclusion:  Initial limited pilot data suggest that a diagnostic time-out and diagnostic checklist, the novel mnemonic “Investigators THINK”, may be useful in raising awareness to prevent cognitive error. Next steps include a qualitative analysis of "think-out-loud" video footage from this and subsequent simulated scenarios to look at themes reflective of critical thinking skills.  Subsequent sessions will have longer session times, pre-session simulations and 3 month post-surveys to assess practical use of the THINK checklist. Future work will include a randomized control trial to assess the effect on diagnostic accuracy.