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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.
3
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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.
6
Download The Cognitive Autopsy A Root Cause
Analysis of Medical Decision Making 1st Edition
Kindle