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Checklists to Reduce Diagnostic Errors

Ely, John W. MD; Graber, Mark L. MD; Croskerry, Pat MD, PhD

doi: 10.1097/ACM.0b013e31820824cd
Quality Improvement

Diagnostic errors are common and can often be traced to physicians' cognitive biases and failed heuristics (mental shortcuts). A great deal is known about how these faulty thinking processes lead to error, but little is known about how to prevent them. Faulty thinking plagues other high-risk, high-reliability professions, such as airline pilots and nuclear plant operators, but these professions have reduced errors by using checklists. Recently, checklists have gained acceptance in medical settings, such as operating rooms and intensive care units. This article extends the checklist concept to diagnosis and describes three types of checklists: (1) a general checklist that prompts physicians to optimize their cognitive approach, (2) a differential diagnosis checklist to help physicians avoid the most common cause of diagnostic error—failure to consider the correct diagnosis as a possibility, and (3) a checklist of common pitfalls and cognitive forcing functions to improve evaluation of selected diseases. These checklists were developed informally and have not been subjected to rigorous evaluation. The purpose of this article is to argue for the further investigation and revision of these initial attempts to apply checklists to the diagnostic process. The basic idea behind checklists is to provide an alternative to reliance on intuition and memory in clinical problem solving. This kind of solution is demanded by the complexity of diagnostic reasoning, which often involves sense-making under conditions of great uncertainty and limited time.


Dr. Ely is professor, Department of Family Medicine, University of Iowa, Iowa City, Iowa.

Dr. Graber is chief of medicine, Department of Veterans Affairs Hospital, Northport, New York, and professor and associate chair, Department of Internal Medicine, State University of New York, Stony Brook, New York.

Dr. Croskerry is professor of emergency medicine, Dalhousie University, Halifax, Nova Scotia, Canada.

Editor's Note: A commentary on this article appears on page 279.

Correspondence should be addressed to Dr. Ely, Department of Family Medicine, 01291-D, PFP, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242; telephone: (319) 384-7533; fax: (319) 384-7822; e-mail:

First published online January 18, 2011

Supplemental digital content for this article is available at

© 2011 Association of American Medical Colleges