Errors in clinical reasoning: causes and remedial strategies.

Ian A. Scott

Commentary

Errors in clinical reasoning: causes and remedial strategies.

June 24, 2009

Scott IA. BMJ. 2009;338:b1860.

View more articles from the same authors.

This commentary analyzes how cognitive errors occur and shares strategies to minimize their incidence and impact.

PubMed citation

Available at

Related Resources From the Same Author(s)

COVID-19 pandemic and the tension between the need to act and the need to know.

October 14, 2020

The gaps in specialists' diagnoses.

April 11, 2018

Patient harm from cardiovascular medications.

August 25, 2021

Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis.

January 14, 2015

Minimizing inappropriate medications in older populations: a ten-step conceptual framework.

April 4, 2012

Using EMR-enabled computerized decision support systems to reduce prescribing of potentially inappropriate medications: a narrative review.

October 10, 2018

Countering cognitive biases in minimising low value care.

June 7, 2017

Developing critical thinking skills for delivering optimal care

July 28, 2021

An adverse event screening tool based on routinely collected hospital-acquired diagnoses.

May 30, 2012

Scoping review of studies evaluating frailty and its association with medication harm.

June 22, 2022

Medication use and cognitive impairment among residents of aged care facilities.

June 23, 2021

Communication errors in radiology—pitfalls and how to avoid them.

August 1, 2018

Why do interns make prescribing errors? A qualitative study.

February 13, 2008

An evaluation of medication errors—the pediatric surgical service experience.

March 5, 2008

Reducing inappropriate polypharmacy: the process of deprescribing.

April 1, 2015

The role of the patient in patient safety: what can we learn from healthcare's history?

August 29, 2018

Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality.

May 13, 2020

What is needed to sustain improvements in hospital practices post-COVID-19? A qualitative study of interprofessional dissonance in hospital infection prevention and control.

May 4, 2022

Putting knowledge into practice: does information on adverse drug interactions influence people's dosing behaviour?

February 22, 2017

Do no harm: is it time to rethink the Hippocratic Oath?

February 5, 2014

Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises.

April 29, 2020

Clinical predictors for unsafe direct discharge home patients from intensive care units.

October 21, 2020

Learning from error: identifying contributory causes of medication errors in an Australian hospital.

March 19, 2008

The uptake of technologies designed to influence medication safety in Canadian hospitals.

February 20, 2008

Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review.

March 25, 2020

Communicating in the "gray zone": perceptions about emergency physician-hospitalist handoffs and patient safety.

October 17, 2007

Detection of patient risk by nurses: a theoretical framework.

February 17, 2010

Implementing a human factors approach to RCA(2) : tools, processes and strategies.

March 10, 2021

Safety first! Using a checklist for intrafacility transport of adult intensive care patients.

October 21, 2015

Differing perceptions of safety culture across job roles in the ambulatory setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture.

November 11, 2015

Utility of an online medication-error-reporting system.

November 23, 2005

Patient and family engagement in incident investigations: exploring hospital manager and incident investigators' experiences and challenges.

October 31, 2018

Sepsis quality in safety-net hospitals: an analysis of Medicare's SEP-1 performance measure.

October 2, 2019

A systematic review of patient tracking systems for use in the pediatric emergency department.

June 6, 2012

Beyond the team: understanding interprofessional work in two North American ICUs.

August 19, 2015

Reducing falls and fall-related injuries in mental health: a 1-year multihospital falls collaborative.

November 13, 2013

Automation of the I-PASS tool to improve transitions of care.

October 23, 2019

Medication errors in mental healthcare: a systematic review.

December 20, 2006

CDC central-line bloodstream infection prevention efforts produced net benefits of at least $640 million during 1990–2008.

June 18, 2014

Associations between in-hospital mortality, health care utilization, and inpatient costs with the 2011 resident duty hour revision.

May 15, 2019

The admission conference call: a novel approach to optimizing pediatric emergency department to admitting floor communication.

May 29, 2019

Using patient safety reporting systems to understand the clinical learning environment: a content analysis.

January 9, 2019

Potential drug interactions and duplicate prescriptions among cancer patients.

May 2, 2007

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

Caregiver fatigue: implications for patient and staff safety—part 1 and part 2.

September 7, 2016

Applying ethnography to the study of context in healthcare quality and safety.

January 22, 2014

Role of registered nurses in error prevention, discovery and correction.

April 16, 2008

Promoting a culture of patient safety: a review of the Florida moratoria data: what we have learned in 6 years and the need for continued patient education.

April 4, 2007

"Good catch, Kiddo"--enhancing patient safety in the pediatric emergency department through simulation.

December 9, 2020

The doctor was rude, the toilets are dirty. Utilizing 'soft signals' in the regulation of patient safety.

November 4, 2020

A systematic review of natural language processing for classification tasks in the field of incident reporting and adverse event analysis.

November 20, 2019

A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people.

April 10, 2019

Paediatric dosing errors before and after electronic prescribing.

August 18, 2010

What methods are used to apply positive deviance within healthcare organisations? A systematic review.

March 2, 2016

Learning from incidents in healthcare: the journey, not the arrival, matters.

April 27, 2016

Patient safety in patients who occupy beds on clinically inappropriate wards: a qualitative interview study with NHS staff.

December 7, 2011

Performance variability in perioperative sentinel events: report on a nationwide data set.

April 20, 2022

Resident wellness in US ophthalmic graduate medical education: the resident perspective.

May 23, 2018

The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop.

December 21, 2016

Influencing leadership perceptions of patient safety through just culture training.

May 5, 2010

Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings.

October 6, 2021

Test result communication in primary care: clinical and office staff perspectives.

August 20, 2014

Learning not to take it seriously: junior doctors' accounts of error.

October 15, 2008

Why patient safety is such a tough nut to crack.

July 6, 2011

An ethnographic study of health information technology use in three intensive care units.

August 30, 2017

Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME.

August 30, 2017

The association between organizational culture and the ability to benefit from "just culture" training.

March 6, 2019

Semi-supervised classification of patient safety event reports.

June 6, 2012

Clinical features and preventability of delayed diagnosis of pediatric appendicitis.

September 29, 2021

Hospital acquired infections in surgical patients: impact of COVID-19-related infection prevention measures.

April 20, 2022

Predicting avoidable hospital events in Maryland.

December 1, 2021

The role of communication in paediatric drug safety.

May 23, 2007

Adverse events following an emergency department visit.

February 28, 2007

Systemic error in radiology.

August 9, 2017

Interprofessional care in intensive care settings and the factors that impact it: results from a scoping review of ethnographic studies.

September 4, 2013

The frequency and significance of discrepancies in the surgical count.

August 27, 2008

Unit of measurement used and parent medication dosing errors.

July 30, 2014

Survival from in-hospital cardiac arrest during nights and weekends.

February 27, 2008

Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.

March 17, 2010

The debrief imperative: building teaming competencies and team effectiveness.

November 16, 2022

Structural iatrogenesis—a 43-year-old man with "opioid misuse."

March 6, 2019

Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: a cluster-randomized trial.

July 26, 2017

A strategic approach for managing conflict in hospitals: responding to The Joint Commission leadership standard—part 1 and part 2.

January 26, 2011

The incidence and nature of prescribing and medication administration errors in paediatric inpatients.

February 24, 2010

Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy.

May 26, 2010

A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery.

September 22, 2021

Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions.

August 31, 2022

ICU attending handoff practices: results from a national survey of academic intensivists.

December 9, 2015

Nursing home error and level of staff credentials.

April 18, 2007

Methicillin-resistant Staphylococcus aureus central line–associated bloodstream infections in US intensive care units, 1997-2007.

February 18, 2009

Medication safety teams' guided implementation of electronic medication administration records in five nursing homes.

January 14, 2009

Speaking up about safety concerns: multi-setting qualitative study of patients' views and experiences.

December 15, 2010

Accuracy in patient understanding of common medical phrases.

December 21, 2022

The July Effect in podiatric medicine and surgery residency.

July 14, 2021

Operating room fires.

February 6, 2019

What do hospital staff in the UK think are the causes of penicillin medication errors?

April 17, 2013

Patient perspectives on test result communication in primary care: a qualitative study.

April 29, 2015

Nurses' perceptions of error communication and reporting in the intensive care unit.

August 13, 2008

Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members.

September 8, 2010

Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.

December 14, 2005

Related Resources

"It's probably an STI because you're gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals.

May 24, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Cognitive bias and dissonance in surgical practice: a narrative review.

April 26, 2023

The woman who cried pain: do sex-based disparities still exist in the experience and treatment of pain?

February 8, 2023

Pursuit of "endpoint diagnoses" as a cognitive forcing strategy to avoid premature diagnostic closure.

December 21, 2022

Affective influences on clinical reasoning and diagnosis: insights from social psychology and new research opportunities.

October 19, 2022

Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis.

September 14, 2022

Patterns of error in interpretive pathology.

August 17, 2022

Developing critical thinking skills for delivering optimal care

July 28, 2021

Gender biases in estimation of others' pain.

April 28, 2021

What COVID-19 teaches us about implicit bias in pediatric health care.

February 24, 2021

The critical need for nursing education to address the diagnostic process.

February 17, 2021

Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution.

November 11, 2020

Understanding context specificity: the effect of contextual factors on clinical reasoning.

September 2, 2020

The role of cognitive bias in breast radiology diagnostic and judgment errors.

May 27, 2020

Clinical reasoning as a core competency.

October 30, 2019

Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care

October 2, 2019

What causes prescribing errors in children? Scoping review.

August 28, 2019

Framing of clinical information affects physicians' diagnostic accuracy.

August 28, 2019

Intentional rounding—an integrative literature review.

August 7, 2019

What interventions could reduce diagnostic error in emergency departments? A review of evidence, practice and consumer perspectives.

July 24, 2019

Controversies in diagnosis: contemporary debates in the diagnostic safety literature.

July 17, 2019

A simulation-based approach to training in heuristic clinical decision-making.

June 19, 2019

Health Professions Education.

June 12, 2019

Patient Safety.

May 22, 2019

The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.

May 15, 2019

Laney's story: the problem of delayed diagnosis of pediatric stroke.

April 24, 2019

Recommendations from a national panel on quality improvement in obstetrics.

April 24, 2019

Saving without compromising: teaching trainees to safely provide high value care.

April 17, 2019

An IDEA: safety training to improve critical thinking by individuals and teams.

April 10, 2019

See More About The Topic

Health Care Providers

Educators

Diagnostic Errors

Epidemiology of Errors and Adverse Events

Cognitive Errors ("Mistakes")

Errors in clinical reasoning: causes and remedial strategies.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Errors in clinical reasoning: causes and remedial strategies.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site