Abstract
Diagnostic failure has emerged as one of the most significant threats to
patient safety, and it is important to understand the antecedents of
such failures. A consensus has developed in the literature that the
majority are due to individual or system factors or some combination of
the two. A major source of variance in individual clinical performance
is due to cognitive and affective biases, however, their role in
clinical decision making has been difficult to assess partly because
they are difficult to investigate experimentally. A significant drawback
has been that experimental manipulations appear to confound assessment
of the context surrounding the diagnostic process itself. The present
qualitative study uses a detailed narrative account of selected actual
cases of diagnostic error to explore the effect of biases in the ‘real
world’ emergency medicine (EM) context. Thirty anonymized EM cases were
analysed in depth through a process of root cause analysis that included
an assessment of error producing conditions, knowledge-based errors, and
how clinicians were thinking and deciding during each case. A prominent
feature of the study was the identification of specific cognitive and
affective biases – through a process called cognitive autopsy. The
cases covered a broad range of diagnoses across a wide variety of
disciplines. A total of 24 discrete cognitive and affective biases that
contributed to misdiagnosis were identified and their incidence
recorded. 5-6 biases were detected per case, and observed on 168
occasions across the 30 cases. Thirteen error-producing conditions
(EPCs) were identified. Knowledge-based errors were rare, occurring in
only 5 definite instances. The ordinal position in which biases appeared
in the diagnostic process was recorded. This study provides a base-line
for understanding the critical role that biases play in clinical
decision making and sheds light on important aspects of the diagnostic
process.