The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them
Croskerry, Pat MD, PhD
Dr. Croskerry is associate professor, Departments of Emergency Medicine and Medical Education, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada. He is also a member of the Center for Safety in Emergency Care, a research consortium of the University of Florida College of Medicine, Dalhousie University Faculty of Medicine, Northwestern University The Feinberg School of Medicine, and Brown Medical School.
Correspondence and requests for reprints should be sent to Dr. Croskerry, Emergency Department, Dartmouth General Hospital Site, Capital District, 325 Pleasant Street, Dartmouth, Nova Scotia, Canada B2Y 4G8; telephone: (902) 465-8491; fax: (902) 460-4148; e-mail: 〈firstname.lastname@example.org〉.
The author gratefully acknowledges support through a Senior Clinical Research Fellowship from the Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada, and a grant (#P20HS11592-02) awarded by the Agency for Healthcare Research and Quality.
Two responses to this article are printed after it.
In the area of patient safety, recent attention has focused on diagnostic error. The reduction of diagnostic error is an important goal because of its associated morbidity and potential preventability. A critical subset of diagnostic errors arises through cognitive errors, especially those associated with failures in perception, failed heuristics, and biases; collectively, these have been referred to as cognitive dispositions to respond (CDRs). Historically, models of decision-making have given insufficient attention to the contribution of such biases, and there has been a prevailing pessimism against improving cognitive performance through debiasing techniques. Recent work has catalogued the major cognitive biases in medicine; the author lists these and describes a number of strategies for reducing them (“cognitive debiasing”). Principle among them is metacognition, a reflective approach to problem solving that involves stepping back from the immediate problem to examine and reflect on the thinking process. Further research effort should be directed at a full and complete description and analysis of CDRs in the context of medicine and the development of techniques for avoiding their associated adverse outcomes. Considerable potential exists for reducing cognitive diagnostic errors with this approach. The author provides an extensive list of CDRs and a list of strategies to reduce diagnostic errors.
The recent article by Graber et al.1 provides a comprehensive overview of diagnostic errors in medicine. There is, indeed, a long overdue and pressing need to focus on this area. They raise many important points, several of which deserve extra emphasis in the light of recent developments. They also provide an important conceptual framework within which strategies may be developed to minimize errors in this critical aspect of patient safety. Diagnostic errors are associated with a proportionately higher morbidity than is the case with other types of medical errors.2–4
The no-fault and system-related categories of diagnostic errors described1 certainly have the potential for reduction. In fact, very simple changes to the system could result in a significant reduction in these errors. However, the greatest challenge, as they note, is the minimization of cognitive errors, and specifically the biases and failed heuristics that underlie them. Historically, there has prevailed an unduly negative mood toward tackling cognitive bias and finding ways to minimize or eliminate it.
The cognitive revolution in psychology that took place over the last 30 years gave rise to an extensive, empirical literature on cognitive bias in decision-making, but this advance has been ponderously slow to enter medicine. Decision-making theorists in medicine have clung to normative, often robotic, models of clinical decision making that have little practical application in the real world of decision making. What is needed, instead, is a systematic analysis of what Reason5 has called “flesh and blood” decision-making. This is the real decision making that occurs at the front line, when resources are in short supply, when time constraints apply, and when shortcuts are being sought. When we look more closely at exactly what cognitive activity is occurring when these clinical decisions are being made, we may be struck by how far it is removed from what normative theory describes. Although it seems certain we would be less likely to fail patients diagnostically when we follow rational, normative models of decision making, and although such models are deserving of “a prominent place in Plato's heaven of ideas,”6 they are impractical at the sharp end of patient care. Cognitive diagnostic failure is inevitable when exigencies of the clinical workplace do not allow such Olympian cerebral approaches.
Medical decision makers and educators have to do three things: (1) appreciate the full impact of diagnostic errors in medicine and the contribution of cognitive errors in particular; (2) refute the inevitability of cognitive diagnostic errors; and (3) dismiss the pessimism that surrounds approaches for lessening cognitive bias.
For the first, the specialties in which diagnostic uncertainty is most evident and in which delayed or missed diagnoses are most likely are internal, family, and emergency medicine; this is borne out in findings from the benchmark studies of medical error.2–4 However, all specialties are vulnerable to this particular adverse event. The often impalpable nature of diagnostic error perhaps reflects why it does not appear in lists of serious reportable events.7 For the second, there needs to be greater understanding of the origins of the widespread inertia that prevails against reducing or eliminating cognitive errors. This inertia may exist because such errors appear to be so predictable, so widespread among all walks of life, so firmly entrenched, and, therefore, probably hardwired. Although the evolutionary imperatives that spawned them may have served us well in earlier times, it now seems we are left with cognitively vestigial approaches to the complex decision making required of us in the modern world. Although “cognitive firewalls” may have evolved to quarantine or avoid cognitive errors, they are clearly imperfect8 and will require ontogenetic assistance (i.e., cognitive debiasing) to avoid their consequences. Accepting this, we should say less about biases and failed heuristics and more about cognitive dispositions to respond (CDRs) to particular situations in various predictable ways. Removing the stigma of bias clears the way toward accepting the capricious nature of decision-making, and perhaps goes some way toward exculpating clinicians when their diagnoses fail.
An understanding of why clinicians have particular CDRs in particular clinical situations will throw considerable light on cognitive diagnostic errors. The unmasking of cognitive errors in the diagnostic process then allows for the development of debiasing techniques. This should be the ultimate goal, and it is not unrealistic.
Certainly, a number of clear strategies exist for reducing the memory limitations and excessive cognitive loading1 that can lead to diagnostic errors, but the most important strategy may well lie in familiarizing clinicians with the various types of CDRs that are out there, and how they might be avoided. I made a recent extensive trawl of medical and psychological literature, which revealed at least 30 CDRs,9 and there are probably more (List 1). This catalogue provides some idea of the extent of cognitive bias on decision-making and gives us a working language to describe it. The failures to show improvement in decision support for clinical diagnosis that are noted by Graber et al.1 should come as no surprise. They are likely due to insufficient awareness of the influence of these CDRs, which is often subtle and covert.10 There appears to have been an historic failure to fully appreciate, and therefore capture, where the most significant diagnostic failures are coming from.
Not surprisingly, all CDRs are evident in emergency medicine, a discipline that has been described as a “natural laboratory of error.”11 In this milieu, decision-making is often naked and raw, with its flaws highly visible. Nowhere in medicine is rationality more bounded by relatively poor access to information and with limited time to process it, all within a milieu renowned for its error-producing conditions.12 It is where heuristics dominate, and without them emergency departments would inexorably grind to a halt.13 Best of all, for those who would like to study real decision making, it is where heuristics can be seen to catastrophically fail. Approximately half of all litigation brought against emergency physicians arises from delayed or missed diagnoses.14
If we accept the pervasiveness and predictability of the CDRs that underlie diagnostic cognitive error, then we are obliged to search for effective debiasing techniques. Despite the prevailing pessimism, it has been demonstrated that, using a variety of strategies15,16 (Table 1), CDRs can be overcome for a number of specific biases.16–23 It appears that there are, indeed, cognitive pills for cognitive ills,22 which makes intuitive sense. This is fortunate, for otherwise, how would we learn to avoid pitfalls, develop expertise, and acquire clinical acumen, particularly if the predisposition for certain cognitive errors is hardwired? However, medical educators should be aware that if the pills are not sufficiently sugared, they may not be swallowed.
Yates et al.24 have summarized some of the major impediments that have stood in the way of developing effective cognitive debiasing strategies, and they are not insurmountable. The first step is to overcome the bias against overcoming bias. Metacognition will likely be the mainstay of this approach. A recent cognitive debiasing technique using cognitive forcing strategies is based on metacognitive principles10 and seems to be teachable to medical undergraduates and postgraduates.25 Essentially, the strategy requires first that the learner be aware of the various cognitive pitfalls, and second that specific forcing strategies be developed to counter them.
Much of clinical decision making, as Reason5 notes, is where “the cognitive reality departs from the formalized ideal.” This cognitive reality is extremely vulnerable to error. The problem is that cognitive error is high-hanging fruit and difficult to get at, and there will be a tendency to pursue more readily attainable goals. There is a story about a jogger who came across a man on his knees under a streetlight one evening. He explained that he had dropped his wedding ring. The jogger offered to help him search, and he accepted. With no luck after a half hour, the jogger asked the man if he was sure he had dropped the ring at the place where they were searching. The man replied that he actually dropped it several yards away in the shadows. “Then why are we looking here?” asked the jogger. “Because the light is better,” came the reply.
Real solutions to cognitive diagnostic errors lie in the shadows, and they will be difficult to find. One very clear goal in reducing diagnostic errors in medicine is to first describe, analyze, and research CDRs in the context of medical decision making, and to then find effective ways of cognitively debiasing ourselves and those whom we teach. Not only should we be able to reduce many cognitive diagnostic errors, but we may also be pleasantly surprised to find how many can be eliminated.
1. Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what's the goal? Acad Med. 2002;77:981–92.
2. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study 1. N Eng J Med. 1991;324:370–6.
3. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Australia 1995;163:458–71.
4. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261–2.
5. Reason, J. Human Error. New York: Cambridge University Press, 1990.
6. Simon HA. Alternate visions of rationality. In: Arkes HR, Hammond KR (eds.). Judgment and Decision Making: An Interdisciplinary Reader. New York: Cambridge University Press, 1986: 97–113.
7. Serious reportable events in patient safety: A National Quality Forum consensus report. Washington, D.C.: National Quality Forum, 2002.
8. Cosmides L, Tooby J. Consider the source: the evolution of adaptations for decoupling and metarepresentation. In: Sperber D (ed.). Metarepresentation. Vancouver Studies in Cognitive Science. New York: Oxford University Press, 2001.
9. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med 2002;9:1184–1204.
10. Croskerry P. Cognitive forcing strategies in clinical decision making. Ann Emerg Med. 2003;41:110–20.
11. Bogner, MS. (ed.). Human Error in Medicine. New Jersey: Lawrence Erlbaum Associates, 1994.
12. Croskerry P, Wears RL. Safety errors in emergency medicine. In: Markovchick VJ and Pons PT (eds.). Emergency Medicine Secrets, 3rd ed. Philadelphia: Hanley and Belfus, 2002: 29–37.
13. Kovacs G, Croskerry P. Clinical decision making: an emergency medicine perspective. Acad Emerg Med. 1999;6:947–52.
14. Data from the U.S General Accounting Office, the Ohio Hospital Association and the St. Paul (MN) Insurance Company, 1998 〈http://hookman.com/mp9807.htm
〉. Accessed 4/24/03.
15. Fischhoff B. Debiasing. In: Kahneman D. Slovic P. and Tversky A (eds). Judgment under Uncertainty: Heuristics and Biases. New York: Cambridge University Press, 1982: 422–44.
16. Arkes HA. Impediments to accurate clinical judgment and possible ways to minimize their impact. In: Arkes HR, Hammond KR (eds). Judgment and Decision Making: An Interdisciplinary Reader. New York: Cambridge University Press, 1986: 582–92.
17. Nathanson S, Brockner J, Brenner D, et al. Toward the reduction of entrapment. J Applied Soc Psychol. 1982;12:193–208.
18. Schwartz WB, Gorry GA, Kassirer JP, Essig A. Decision analysis and clinical judgment. Am J Med. 1973;55:459–72.
19. Slovic P, Fischhoff B. On the psychology of experimental surprises. J Exp Psychol Hum Percept Perform. 1977;3:544–51.
20. Edwards W, von Winterfeldt D. On cognitive illusions and their implications. In: Arkes HR, Hammond KR (eds). Judgment and Decision Making: An Interdisciplinary Reader. New York: Cambridge University Press, 1986: 642–79.
21. Wolf FM, Gruppen LD, Billi JE. Use of a competing-hypothesis heuristic to reduce pseudodiagnosticity. J Med Educ 1988;63:548–54.
22. Keren G. Cognitive aids and debiasing methods: can cognitive pills cure cognitive ills? In: Caverni JP, Fabre JM, Gonzales M (eds). Cognitive Biases. New York: Elsevier, 1990: 523–52.
23. Plous S. The Psychology of Judgment and Decision Making. Philadelphia: Temple University Press, 1993.
24. Yates JF, Veinott ES, Patalano AL. Hard decisions, bad decisions: on decision quality and decision aiding. In: Schneider S, Shanteau J. (eds.). Emerging Perspectives in Judgment and Decision Making. New York: Cambridge University Press, 2003.
25. Croskerry P. Cognitive forcing strategies in emergency medicine. Emerg Med J. 2002;19(suppl 1):A9.
26. Croskerry P. The feedback sanction. Acad Emerg Med. 2000;7:1232–38.
27. Hogarth RM. Judgment and Choice: The Psychology of Decision. Chichester, England: Wiley, 1980.
This article has been cited 119 time(s).
Revista Clinica EspanolaPremature diagnostic closure: an avoidable type of errorRevista Clinica Espanola
Clinical Infectious DiseasesDecision Making During Healthcare-Associated Infection Surveillance: A Rationale for AutomationClinical Infectious Diseases
Memory & CognitionAn eye for relations: eye-tracking indicates long-term negative effects of operational thinking on understanding of math equivalenceMemory & Cognition
American Journal of MedicineDigging Deeper into DyspneaAmerican Journal of Medicine
Advances in Health Sciences EducationAutomated detection of heuristics and biases among pathologists in a computer-based systemAdvances in Health Sciences Education
Patient Education and CounselingIntegrating clinical communication with clinical reasoning and the broader medical curriculumPatient Education and Counseling
Medical TeacherDoes the think-aloud protocol reflect thinking? Exploring functional neuroimaging differences with thinking (answering multiple choice questions) versus thinking aloudMedical Teacher
Journal of Computer Assisted LearningGeneric reflective feedback: An effective approach to developing clinical reasoning skillsJournal of Computer Assisted Learning
Journal of Continuing Education in the Health ProfessionsReducing Cognitive Skill Decay and Diagnostic Error: Theory-Based Practices for Continuing Education in Health CareJournal of Continuing Education in the Health Professions
Journal of Organizational BehaviorTo reflect or not to reflect: Prior team performance as a boundary condition of the effects of reflexivity on learning and final team performanceJournal of Organizational Behavior
British Journal of Anaesthesia'Sixth sense' for patient safetyBritish Journal of Anaesthesia
Annals of Family MedicineClinical Intuition in Family Medicine: More Than First ImpressionsAnnals of Family Medicine
Diagnostic Microbiology and Infectious DiseaseDiagnostic dilemma in a returning traveler with feverDiagnostic Microbiology and Infectious Disease
Social Science & MedicineDoes inappropriate selectivity in information use relate to diagnostic errors and patient harm? The diagnosis of patients with dyspneaSocial Science & Medicine
Journal of Clinical Child and Adolescent PsychologyFuture Directions in Psychological Assessment: Combining Evidence-Based Medicine Innovations with Psychology's Historical Strengths to Enhance UtilityJournal of Clinical Child and Adolescent Psychology
Medical TeacherEffect of enhanced analytic reasoning on diagnostic accuracy: A randomized controlled studyMedical Teacher
American Journal of Emergency MedicineUltrasound to reduce cognitive errors in the EDAmerican Journal of Emergency Medicine
American Journal of RoentgenologyCognitive and System Factors Contributing to Diagnostic Errors in RadiologyAmerican Journal of Roentgenology
Information and Software TechnologyMore testers - The effect of crowd size and time restriction in software testingInformation and Software Technology
Medical EducationA hinting strategy for online learning of radiograph interpretation by medical studentsMedical Education
Medical TeacherEffects of the use of differential diagnosis checklist and general de-biasing checklist on diagnostic performance in comparison to intuitive diagnosisMedical Teacher
Clinical BiochemistryAssessing physician utilization of laboratory practice guidelines: Barriers and opportunities for improvementClinical Biochemistry
Current Problems in Pediatric and Adolescent Health CareDiagnostic Decision-Making and Strategies to Improve DiagnosisCurrent Problems in Pediatric and Adolescent Health Care
Current Problems in Pediatric and Adolescent Health CareEducational Strategies for Improving Clinical ReasoningCurrent Problems in Pediatric and Adolescent Health Care
Journal of General Internal MedicineMore than Skin DeepJournal of General Internal Medicine
Clinical Infectious DiseasesClinical Reasoning for the Infectious Disease Specialist: A Primer to Recognize Cognitive BiasesClinical Infectious Diseases
European Journal of Internal MedicineCognitive diagnostic error in internal medicineEuropean Journal of Internal Medicine
Clinical Social Work Journal"Walking the Tightrope:" Clinical Social Workers' Use of Diagnostic and Environmental PerspectivesClinical Social Work Journal
British Medical Journal
Commentary: Can we avoid bias?
British Medical Journal, 330():
Veterinary Clinics of North America-Food Animal PracticeDetermining cause and effect in herdsVeterinary Clinics of North America-Food Animal Practice
American Journal of MedicineOverconfidence as a cause of diagnostic error in medicineAmerican Journal of Medicine
Journal of the American Academy of Nurse PractitionersAn uncommon skin condition illustrates the need for caution when prescribing for friendsJournal of the American Academy of Nurse Practitioners
Medical Science Monitor
Clinical case reports and case series research in evaluating surgery. Part I. The context: General aspects of evaluation applied to surgery
Medical Science Monitor, 14(9):
Journal of Medical Imaging and Radiation OncologyParallel diagnostic universes: One patientJournal of Medical Imaging and Radiation Oncology
Advances in Health Sciences EducationCognitive elements in clinical decision-makingAdvances in Health Sciences Education
American Journal of RoentgenologyBiases in Radiologic ReasoningAmerican Journal of Roentgenology
Advances in Health Sciences EducationDual processing and diagnostic errorsAdvances in Health Sciences Education
Journal of the American Medical Informatics AssociationUse of population health data to refine diagnostic decision-making for pertussisJournal of the American Medical Informatics Association
Archives of Internal Medicine
Diagnostic error in internal medicine
Archives of Internal Medicine, 165():
Archives of Internal Medicine
Diagnostic Error in Medicine Analysis of 583 Physician-Reported Errors
Archives of Internal Medicine, 169():
Archives of Internal Medicine
Entering the Second Decade of the Patient Safety Movement The Field Matures
Archives of Internal Medicine, 169():
Journal of Biomedical InformaticsTiMeDDx - A multi-phase anchor-based diagnostic decision-support modelJournal of Biomedical Informatics
Which patients are most challenging for second-year medical students?
Family Medicine, 36():
Archives of Internal Medicine
Missed hypothyroidism diagnosis uncovered by linking laboratory and pharmacy data
Archives of Internal Medicine, 165(5):
Annals of Internal Medicine
Graduate medical education and patient safety: A busy-and occasionally hazardous-intersection
Annals of Internal Medicine, 145(8):
Journal of Clinical Ethics
Uncertainty and moral judgment: The limits of reason in genetic decision making
Journal of Clinical Ethics, 18(2):
Journal of Continuing Education in the Health ProfessionsRepresentational fluency in HIV clinical practice: A model of instructor discourseJournal of Continuing Education in the Health Professions
Advances in Health Sciences EducationDiagnostic error in medicine: introductionAdvances in Health Sciences Education
Occupational Medicine-OxfordThe importance of thinking in occupational medicineOccupational Medicine-Oxford
Academic Emergency MedicineClinical decision rules "in the real world": How a widely disseminated rule is used in everyday practiceAcademic Emergency Medicine
Annals of Saudi Medicine
Towards evidence-based diagnosis in developing countries: The use of likelihood ratios for robust quick diagnosis
Annals of Saudi Medicine, 26(3):
Medical EducationEffects of reflective practice on the accuracy of medical diagnosesMedical Education
American Journal of Occupational Therapy
Embracing Ambiguity: Facing the Challenge of Measurement
American Journal of Occupational Therapy, 62(6):
Journal of Emergency NursingCharting the Course for Triage DecisionsJournal of Emergency Nursing
Advances in Health Sciences EducationEducational strategies to reduce diagnostic error: can you teach this stuff?Advances in Health Sciences Education
Advances in Health Sciences EducationDiagnostic error in medical education: where wrongs can make rightsAdvances in Health Sciences Education
Journal of the American Medical Informatics AssociationLinking surveillance to action: Incorporation of real-time regional data into a medical decision ruleJournal of the American Medical Informatics Association
Emergency Medicine JournalValidation of a diagnostic reminder system in emergency medicine: a multi-centre studyEmergency Medicine Journal
Journal of Child Psychology and PsychiatryThe Brief Child and Family Phone Interview (BCFPI): 1. Rationale, development, and description of a computerized children's mental health intake and outcome assessment toolJournal of Child Psychology and Psychiatry
Best Practice & Research in Clinical Obstetrics & GynaecologyTowards safe practice in instrumental vaginal deliveryBest Practice & Research in Clinical Obstetrics & Gynaecology
Jama-Journal of the American Medical Association
Diagnostic Errors and Patient Safety
Jama-Journal of the American Medical Association, 302(3):
Medical EducationDiagnostic error and clinical reasoningMedical Education
Medical EducationSelf-reflection on the quality of decisions in health careMedical Education
Medical EducationThe search-inference framework: a proposed strategy for novice clinical problem solvingMedical Education
Internal and Emergency MedicineRational error in internal medicineInternal and Emergency Medicine
Sociology of Health & IllnessWhat happens along the diagnostic pathway to CHD treatment? Qualitative results concerning cognitive processesSociology of Health & Illness
Advances in Health Sciences EducationInformation-gathering patterns associated with higher rates of diagnostic errorAdvances in Health Sciences Education
Academic Emergency MedicineA case study in medical error: The use of the portfolio entryAcademic Emergency Medicine
Psychological Approaches to Chronic Disease Management
Self-management of chronic illness & disease management
Psychological Approaches to Chronic Disease Management, 8():
Influence of Perceived Difficulty of Cases on Physicians' Diagnostic Reasoning
Academic Medicine, 83():
Assessment & Evaluation in Higher EducationAssessment of critical thinking ability in medical studentsAssessment & Evaluation in Higher Education
Revista Medica De Chile
The heuristics of reaching a diagnosis
Revista Medica De Chile, 137():
Telemedicine Journal and E-Health
Perspectives on the patient-provider relationship in primary-care telemedicine
Telemedicine Journal and E-Health, 10(4):
Academic Emergency MedicineProfiles in patient safety: A "Perfect Storm" in the emergency departmentAcademic Emergency Medicine
Medical EducationTeaching from the clinical reasoning literature: combined reasoning strategies help novice diagnosticians overcome misleading informationMedical Education
Emergency Medicine JournalMan versus machine: ignore results at your perilEmergency Medicine Journal
Annals of Internal Medicine
Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims
Annals of Internal Medicine, 145(7):
Pediatrics in Review
Developing a reliable process for narrowing variation
Pediatrics in Review, 27():
Methods of Information in Medicine
Expanding the scope of health information systems - Challenges and developments
Methods of Information in Medicine, 45():
Anaesthesia and Intensive Care
Thoughts about thinking: the challenge for EBM and medical education
Anaesthesia and Intensive Care, 35(5):
Annals of Emergency MedicineRandomized Trial of Computerized Quantitative Pretest Probability in Low-Risk Chest Pain Patients: Effect on Safety and Resource UseAnnals of Emergency Medicine
Annals of Emergency MedicineDo Emergency Physicians Attribute Drug-Related Emergency Department Visits to Medication-Related Problems?Annals of Emergency Medicine
Inflammation ResearchOn the origins and development of evidence-based medicine and medical decision makingInflammation Research
Academic Emergency MedicineThe use of simulation in emergency medicine: A research agendaAcademic Emergency Medicine
Journal of Empirical Research on Human Research EthicsPersonality and ethical decision-making in research: The role of perceptions of self and othersJournal of Empirical Research on Human Research Ethics
Nordic Journal of PsychiatryBarriers in the help-seeking process: A multiple-case study of early-onset dysthymia in SwedenNordic Journal of Psychiatry
Advances in Health Sciences EducationThinking about diagnostic thinking: a 30-year perspectiveAdvances in Health Sciences Education
Social Science & MedicineWhat do physicians gain (and lose) with experience? Qualitative results from a cross-national study of diabetesSocial Science & Medicine
Journal of Evaluation in Clinical PracticeDiagnostic errors and reflective practice in medicineJournal of Evaluation in Clinical Practice
Medical TeacherTwelve tips for teaching avoidance of diagnostic errorsMedical Teacher
HeadachePeer Review: The Success of Headache Depends On Us!Headache
Probability Error in Diagnosis: The Conjunction Fallacy Among Beginning Medical Students
Family Medicine, 41(4):
Annals of Emergency MedicineImproving Handoffs in the Emergency DepartmentAnnals of Emergency Medicine
Information Systems ResearchDSS effectiveness in marketing resource allocation decisions: Reality vs. perceptionInformation Systems Research
Academic Emergency MedicineCognitive and social issues in emergency medicine knowledge translation: A research agendaAcademic Emergency Medicine
Medical EducationBreaking down automaticity: case ambiguity and the shift to reflective approaches in clinical reasoningMedical Education
Human FactorsHuman Factors of the Confirmation Bias in Intelligence Analysis: Decision Support From Graphical Evidence LandscapesHuman Factors
Journal of the American Medical Informatics AssociationCan Cognitive Biases during Consumer Health Information Searches Be Reduced to Improve Decision Making?Journal of the American Medical Informatics Association
Academic Emergency MedicineClinical information systems: Instant ubiquitous clinical data for error reduction and improved clinical outcomesAcademic Emergency Medicine
StrokeMissed diagnosis of subarachnoid hemorrhage in the emergency departmentStroke
Annals of Emergency MedicineCharacteristics of patient care management problems identified in emergency department morbidity and mortality investigations during 15 yearsAnnals of Emergency Medicine
Quality & Safety in Health CareUnderstanding diagnostic errors in medicine: a lesson from aviationQuality & Safety in Health Care
Journal of Clinical Ethics
Diagnosing PVS and minimally conscious state: The role of tacit knowledge and intuition
Journal of Clinical Ethics, 17(1):
Annals of Emergency MedicineEmergency physicians and disclosure of medical errorsAnnals of Emergency Medicine
Surgical Clinics of North AmericaPatient safety and quality in surgerySurgical Clinics of North America
CognitionWhy good thoughts block better ones: The mechanism of the pernicious Einstellung (set) effectCognition
Academic Emergency MedicineCognitive versus technical debriefing after simulation trainingAcademic Emergency Medicine
Annals of Emergency MedicineChest pain: Physician perceptions and decisionmaking in a London emergency departmentAnnals of Emergency Medicine
Journal of Emergency NursingKnow the plan, share the plan, review the risks: A method of structured communication for the emergency care settingJournal of Emergency Nursing
Bmc Medical Informatics and Decision MakingMeasurement properties of the Inventory of Cognitive Bias in Medicine (ICBM)Bmc Medical Informatics and Decision Making
The Neuropsychology of Good Leaders Making Dumb Mistakes
Nursing Economics, 27(2):
Journal of Psychiatric Practice®Challenging the Established Diagnosis in Psychiatric Practice: Is It Worth It?Journal of Psychiatric Practice®
Journal of Psychiatric Practice®Biases in Medication Prescribing: The Case of Second-Generation AntipsychoticsJournal of Psychiatric Practice®
© 2003 Association of American Medical Colleges