Author: National Academies of Sciences, Engineering, and Medicine
Publisher: National Academies Press
ISBN: 0309377722
Category : Medical
Languages : en
Pages : 473
Book Description
Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.
Improving Diagnosis in Health Care
Author: National Academies of Sciences, Engineering, and Medicine
Publisher: National Academies Press
ISBN: 0309377722
Category : Medical
Languages : en
Pages : 473
Book Description
Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.
Publisher: National Academies Press
ISBN: 0309377722
Category : Medical
Languages : en
Pages : 473
Book Description
Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.
Cognitive Errors and Diagnostic Mistakes
Author: Jonathan Howard
Publisher: Springer
ISBN: 3319932241
Category : Medical
Languages : en
Pages : 589
Book Description
This case-based book illustrates and explores common cognitive biases and their consequences in the practice of medicine. The book begins with an introduction that explains the concept of cognitive errors and their importance in clinical medicine and current controversies within healthcare. The core of the book features chapters dedicated to particular cognitive biases; cases are presented and followed by a discussion of the clinician's rationale and an overview of the particular cognitive bias. Engaging and easy to read, this text provides strategies on minimizing cognitive errors in various medical and professional settings.
Publisher: Springer
ISBN: 3319932241
Category : Medical
Languages : en
Pages : 589
Book Description
This case-based book illustrates and explores common cognitive biases and their consequences in the practice of medicine. The book begins with an introduction that explains the concept of cognitive errors and their importance in clinical medicine and current controversies within healthcare. The core of the book features chapters dedicated to particular cognitive biases; cases are presented and followed by a discussion of the clinician's rationale and an overview of the particular cognitive bias. Engaging and easy to read, this text provides strategies on minimizing cognitive errors in various medical and professional settings.
Error and Uncertainty in Diagnostic Radiology
Author: Michael A. Bruno
Publisher: Oxford University Press
ISBN: 0190665416
Category : Medical
Languages : en
Pages : 270
Book Description
Over the past decade, radiological imaging tests - including CT scanning, MRI, PET, X-rays, ultrasound, fluoroscopy and other modalities - have become essential to the routine diagnostic process. While these modern advanced medical images and their striking anatomic detail have discovered underlying issues, they have also contributed to a false impression of infallibility. Unlike other straightforward diagnostic tests, such as the EKG or blood chemistry panel, radiological imaging tests are highly variable and complex, often yielding uncertain results, as well as frequent false-negatives and false-positives. The experts who interpret the images (the diagnostic radiologists) sometimes make mistakes: the practice of diagnostic radiology is a fallible, human endeavour, one involving complex perceptual, neuro-physiological and cognitive processes employed under a wide range of circumstances, and with a great deal of variability. Error and Uncertainty in Diagnostic Radiology opens the 'black box,' of medical imaging, exposing the remarkable inner workings of the process of diagnostic radiology-including how and why it can sometimes go tragically wrong. The occurrence of radiological error is shown to be fundamentally intertwined with the underlying high level of uncertainty known to be present in the diagnostic process. As a foremost expert on radiology quality and safety, Dr. Bruno provides insight into the various types of radiologist error, along with a conceptual framework for understanding error and uncertainty in radiology, leading to practical strategies for error prevention and for reducing the risk of harm to patients when errors inevitably occur. This book is essential for radiologists, members of the Society to Improve Diagnosis in Medicine, emergency physicians, medical educators, medical and hospice administrators, especially quality and safety officers, as well as malpractice insurance carriers.
Publisher: Oxford University Press
ISBN: 0190665416
Category : Medical
Languages : en
Pages : 270
Book Description
Over the past decade, radiological imaging tests - including CT scanning, MRI, PET, X-rays, ultrasound, fluoroscopy and other modalities - have become essential to the routine diagnostic process. While these modern advanced medical images and their striking anatomic detail have discovered underlying issues, they have also contributed to a false impression of infallibility. Unlike other straightforward diagnostic tests, such as the EKG or blood chemistry panel, radiological imaging tests are highly variable and complex, often yielding uncertain results, as well as frequent false-negatives and false-positives. The experts who interpret the images (the diagnostic radiologists) sometimes make mistakes: the practice of diagnostic radiology is a fallible, human endeavour, one involving complex perceptual, neuro-physiological and cognitive processes employed under a wide range of circumstances, and with a great deal of variability. Error and Uncertainty in Diagnostic Radiology opens the 'black box,' of medical imaging, exposing the remarkable inner workings of the process of diagnostic radiology-including how and why it can sometimes go tragically wrong. The occurrence of radiological error is shown to be fundamentally intertwined with the underlying high level of uncertainty known to be present in the diagnostic process. As a foremost expert on radiology quality and safety, Dr. Bruno provides insight into the various types of radiologist error, along with a conceptual framework for understanding error and uncertainty in radiology, leading to practical strategies for error prevention and for reducing the risk of harm to patients when errors inevitably occur. This book is essential for radiologists, members of the Society to Improve Diagnosis in Medicine, emergency physicians, medical educators, medical and hospice administrators, especially quality and safety officers, as well as malpractice insurance carriers.
To Err Is Human
Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309068371
Category : Medical
Languages : en
Pages : 312
Book Description
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine
Publisher: National Academies Press
ISBN: 0309068371
Category : Medical
Languages : en
Pages : 312
Book Description
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine
Diagnostic Error
Author: Pat Croskerry
Publisher:
ISBN: 9781409432340
Category :
Languages : en
Pages : 180
Book Description
Despite diagnosis being the key feature of a physician's clinical performance, this is the first book that deals specifically with the topic. In recent years, however, considerable interest has been shown in this area and significant developments have occurred in two main areas: a) an awareness and increasing understanding of the critical role of clinical decision making in the process of diagnosis, and of the multiple factors that impact it, and b) a similar appreciation of the role of the healthcare system in supporting clinicians in their efforts to make accurate diagnoses. Although medicine has seen major gains in knowledge and technology over the last few decades, there is a consensus that the diagnostic failure rate remains in the order of 10-15%. This book provides an overview of the major issues in this area, in particular focusing on where the diagnostic process fails, and where improvements might be made.
Publisher:
ISBN: 9781409432340
Category :
Languages : en
Pages : 180
Book Description
Despite diagnosis being the key feature of a physician's clinical performance, this is the first book that deals specifically with the topic. In recent years, however, considerable interest has been shown in this area and significant developments have occurred in two main areas: a) an awareness and increasing understanding of the critical role of clinical decision making in the process of diagnosis, and of the multiple factors that impact it, and b) a similar appreciation of the role of the healthcare system in supporting clinicians in their efforts to make accurate diagnoses. Although medicine has seen major gains in knowledge and technology over the last few decades, there is a consensus that the diagnostic failure rate remains in the order of 10-15%. This book provides an overview of the major issues in this area, in particular focusing on where the diagnostic process fails, and where improvements might be made.
When We Do Harm
Author: Danielle Ofri, MD
Publisher: Beacon Press
ISBN: 0807037885
Category : Medical
Languages : en
Pages : 274
Book Description
Medical mistakes are more pervasive than we think. How can we improve outcomes? An acclaimed MD’s rich stories and research explore patient safety. Patients enter the medical system with faith that they will receive the best care possible, so when things go wrong, it’s a profound and painful breach. Medical science has made enormous strides in decreasing mortality and suffering, but there’s no doubt that treatment can also cause harm, a significant portion of which is preventable. In When We Do Harm, practicing physician and acclaimed author Danielle Ofri places the issues of medical error and patient safety front and center in our national healthcare conversation. Drawing on current research, professional experience, and extensive interviews with nurses, physicians, administrators, researchers, patients, and families, Dr. Ofri explores the diagnostic, systemic, and cognitive causes of medical error. She advocates for strategic use of concrete safety interventions such as checklists and improvements to the electronic medical record, but focuses on the full-scale cultural and cognitive shifts required to make a meaningful dent in medical error. Woven throughout the book are the powerfully human stories that Dr. Ofri is renowned for. The errors she dissects range from the hardly noticeable missteps to the harrowing medical cataclysms. While our healthcare system is—and always will be—imperfect, Dr. Ofri argues that it is possible to minimize preventable harms, and that this should be the galvanizing issue of current medical discourse.
Publisher: Beacon Press
ISBN: 0807037885
Category : Medical
Languages : en
Pages : 274
Book Description
Medical mistakes are more pervasive than we think. How can we improve outcomes? An acclaimed MD’s rich stories and research explore patient safety. Patients enter the medical system with faith that they will receive the best care possible, so when things go wrong, it’s a profound and painful breach. Medical science has made enormous strides in decreasing mortality and suffering, but there’s no doubt that treatment can also cause harm, a significant portion of which is preventable. In When We Do Harm, practicing physician and acclaimed author Danielle Ofri places the issues of medical error and patient safety front and center in our national healthcare conversation. Drawing on current research, professional experience, and extensive interviews with nurses, physicians, administrators, researchers, patients, and families, Dr. Ofri explores the diagnostic, systemic, and cognitive causes of medical error. She advocates for strategic use of concrete safety interventions such as checklists and improvements to the electronic medical record, but focuses on the full-scale cultural and cognitive shifts required to make a meaningful dent in medical error. Woven throughout the book are the powerfully human stories that Dr. Ofri is renowned for. The errors she dissects range from the hardly noticeable missteps to the harrowing medical cataclysms. While our healthcare system is—and always will be—imperfect, Dr. Ofri argues that it is possible to minimize preventable harms, and that this should be the galvanizing issue of current medical discourse.
Getting Results
Author:
Publisher:
ISBN:
Category : Medical
Languages : en
Pages : 172
Book Description
Publisher:
ISBN:
Category : Medical
Languages : en
Pages : 172
Book Description
Patient Safety in Emergency Medicine
Author: Pat Croskerry
Publisher: Lippincott Williams & Wilkins
ISBN: 9780781777278
Category : Medical
Languages : en
Pages : 456
Book Description
With the increased emphasis on reducing medical errors in an emergency setting, this book will focus on patient safety within the emergency department, where preventable medical errors often occur. The book will provide both an overview of patient safety within health care—the 'culture of safety,' importance of teamwork, organizational change—and specific guidelines on issues such as medication safety, procedural complications, and clinician fatigue, to ensure quality care in the ED. Special sections discuss ED design, medication safety, and awareness of the 'culture of safety.'
Publisher: Lippincott Williams & Wilkins
ISBN: 9780781777278
Category : Medical
Languages : en
Pages : 456
Book Description
With the increased emphasis on reducing medical errors in an emergency setting, this book will focus on patient safety within the emergency department, where preventable medical errors often occur. The book will provide both an overview of patient safety within health care—the 'culture of safety,' importance of teamwork, organizational change—and specific guidelines on issues such as medication safety, procedural complications, and clinician fatigue, to ensure quality care in the ED. Special sections discuss ED design, medication safety, and awareness of the 'culture of safety.'
Every Patient Tells a Story
Author: Lisa Sanders
Publisher: Harmony
ISBN: 0767922476
Category : Biography & Autobiography
Languages : en
Pages : 305
Book Description
A riveting exploration of the most difficult and important part of what doctors do, by Yale School of Medicine physician Dr. Lisa Sanders, author of the monthly New York Times Magazine column "Diagnosis," the inspiration for the hit Fox TV series House, M.D. "The experience of being ill can be like waking up in a foreign country. Life, as you formerly knew it, is on hold while you travel through this other world as unknown as it is unexpected. When I see patients in the hospital or in my office who are suddenly, surprisingly ill, what they really want to know is, ‘What is wrong with me?’ They want a road map that will help them manage their new surroundings. The ability to give this unnerving and unfamiliar place a name, to know it—on some level—restores a measure of control, independent of whether or not that diagnosis comes attached to a cure. Because, even today, a diagnosis is frequently all a good doctor has to offer." A healthy young man suddenly loses his memory—making him unable to remember the events of each passing hour. Two patients diagnosed with Lyme disease improve after antibiotic treatment—only to have their symptoms mysteriously return. A young woman lies dying in the ICU—bleeding, jaundiced, incoherent—and none of her doctors know what is killing her. In Every Patient Tells a Story, Dr. Lisa Sanders takes us bedside to witness the process of solving these and other diagnostic dilemmas, providing a firsthand account of the expertise and intuition that lead a doctor to make the right diagnosis. Never in human history have doctors had the knowledge, the tools, and the skills that they have today to diagnose illness and disease. And yet mistakes are made, diagnoses missed, symptoms or tests misunderstood. In this high-tech world of modern medicine, Sanders shows us that knowledge, while essential, is not sufficient to unravel the complexities of illness. She presents an unflinching look inside the detective story that marks nearly every illness—the diagnosis—revealing the combination of uncertainty and intrigue that doctors face when confronting patients who are sick or dying. Through dramatic stories of patients with baffling symptoms, Sanders portrays the absolute necessity and surprising difficulties of getting the patient’s story, the challenges of the physical exam, the pitfalls of doctor-to-doctor communication, the vagaries of tests, and the near calamity of diagnostic errors. In Every Patient Tells a Story, Dr. Sanders chronicles the real-life drama of doctors solving these difficult medical mysteries that not only illustrate the art and science of diagnosis, but often save the patients’ lives.
Publisher: Harmony
ISBN: 0767922476
Category : Biography & Autobiography
Languages : en
Pages : 305
Book Description
A riveting exploration of the most difficult and important part of what doctors do, by Yale School of Medicine physician Dr. Lisa Sanders, author of the monthly New York Times Magazine column "Diagnosis," the inspiration for the hit Fox TV series House, M.D. "The experience of being ill can be like waking up in a foreign country. Life, as you formerly knew it, is on hold while you travel through this other world as unknown as it is unexpected. When I see patients in the hospital or in my office who are suddenly, surprisingly ill, what they really want to know is, ‘What is wrong with me?’ They want a road map that will help them manage their new surroundings. The ability to give this unnerving and unfamiliar place a name, to know it—on some level—restores a measure of control, independent of whether or not that diagnosis comes attached to a cure. Because, even today, a diagnosis is frequently all a good doctor has to offer." A healthy young man suddenly loses his memory—making him unable to remember the events of each passing hour. Two patients diagnosed with Lyme disease improve after antibiotic treatment—only to have their symptoms mysteriously return. A young woman lies dying in the ICU—bleeding, jaundiced, incoherent—and none of her doctors know what is killing her. In Every Patient Tells a Story, Dr. Lisa Sanders takes us bedside to witness the process of solving these and other diagnostic dilemmas, providing a firsthand account of the expertise and intuition that lead a doctor to make the right diagnosis. Never in human history have doctors had the knowledge, the tools, and the skills that they have today to diagnose illness and disease. And yet mistakes are made, diagnoses missed, symptoms or tests misunderstood. In this high-tech world of modern medicine, Sanders shows us that knowledge, while essential, is not sufficient to unravel the complexities of illness. She presents an unflinching look inside the detective story that marks nearly every illness—the diagnosis—revealing the combination of uncertainty and intrigue that doctors face when confronting patients who are sick or dying. Through dramatic stories of patients with baffling symptoms, Sanders portrays the absolute necessity and surprising difficulties of getting the patient’s story, the challenges of the physical exam, the pitfalls of doctor-to-doctor communication, the vagaries of tests, and the near calamity of diagnostic errors. In Every Patient Tells a Story, Dr. Sanders chronicles the real-life drama of doctors solving these difficult medical mysteries that not only illustrate the art and science of diagnosis, but often save the patients’ lives.
The Cognitive Autopsy
Author: Pat Croskerry
Publisher: Oxford University Press
ISBN: 0190088753
Category : Medical
Languages : en
Pages : 345
Book Description
Behind heart disease and cancer, medical error is now listed as one of the leading causes of death. Of the many medical errors that may lead to injury and death, diagnostic failure is regarded as the most significant. Generally, the majority of diagnostic failures are attributed to the clinicians directly involved with the patient, and to a lesser extent, the system in which they work. In turn, the majority of errors made by clinicians are due to decision making failures manifested by various departures from rationality. Of all the medical environments in which patients are seen and diagnosed, the emergency department is the most challenging. It has been described as a "wicked" environment where illness and disease may range from minor ailments and complaints to severe, life-threatening disorders. The Cognitive Autopsy is a novel strategy towards understanding medical error and diagnostic failure in 42 clinical cases with which the author was directly involved or became aware of at the time. Essentially, it describes a cognitive approach towards root cause analysis of medical adverse events or near misses. Whereas root cause analysis typically focuses on the observable and measurable aspects of adverse events, the cognitive autopsy attempts to identify covert cognitive processes that may have contributed to outcomes. In this clinical setting, no cognitive process is directly observable but must be inferred from the behavior of the individual clinician. The book illustrates unequivocally that chief among these cognitive processes are cognitive biases and other flaws in decision making, rather than knowledge deficits.
Publisher: Oxford University Press
ISBN: 0190088753
Category : Medical
Languages : en
Pages : 345
Book Description
Behind heart disease and cancer, medical error is now listed as one of the leading causes of death. Of the many medical errors that may lead to injury and death, diagnostic failure is regarded as the most significant. Generally, the majority of diagnostic failures are attributed to the clinicians directly involved with the patient, and to a lesser extent, the system in which they work. In turn, the majority of errors made by clinicians are due to decision making failures manifested by various departures from rationality. Of all the medical environments in which patients are seen and diagnosed, the emergency department is the most challenging. It has been described as a "wicked" environment where illness and disease may range from minor ailments and complaints to severe, life-threatening disorders. The Cognitive Autopsy is a novel strategy towards understanding medical error and diagnostic failure in 42 clinical cases with which the author was directly involved or became aware of at the time. Essentially, it describes a cognitive approach towards root cause analysis of medical adverse events or near misses. Whereas root cause analysis typically focuses on the observable and measurable aspects of adverse events, the cognitive autopsy attempts to identify covert cognitive processes that may have contributed to outcomes. In this clinical setting, no cognitive process is directly observable but must be inferred from the behavior of the individual clinician. The book illustrates unequivocally that chief among these cognitive processes are cognitive biases and other flaws in decision making, rather than knowledge deficits.