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.
If you wish to visit a new place, help is available everywhere: maps, guide books, Internet sites for trip planning, online reviews and personal advice etc. But nothing beats finding a local guide, someone who lives there, and knows the land, its people, culture and "how things work here".That's exactly the role that Pat Croskerry plays in The Cognitive Autopsy - he's our guide to the still-emerging arena of understanding diagnostic error. Pat has spent a long career working on the front lines in emergency medicine, also known as the emergency room (ER) or the emergency department (ED). Pat knows this place like the back of his hand, and is the perfect person to show us around, and orientate us to what there is to see.The Cognitive Autopsy is a unique and fascinating collection of cases that span the spectrum of diagnostic error types and causes seen in the ED. Each one is its own self-contained story, with lessons of cognitive and affective biases. Stories are powerful, and it is said that stories may be how our knowledge base is organized. A diagnosis is itself a story - the medical story that corresponds to and flows from the patient's story"--
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.
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.
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."--
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.
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.
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