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PSNet: Patient Safety Network
Journal Article
Study

Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors.

Gupta A, Harrod M, Quinn M, et al. Diagnosis (Berlin, Germany). 2018;5:151-156.

This direct observation study of hospitalist teams on rounds and conducting follow-up work examined the interaction between systems problems and cognitive errors in diagnosis. Researchers found that information gaps related to electronic health records, challenges with handoffs, and time constraints all contributed to difficulties in diagnostic cognition. The authors suggest considering both systems and cognitive challenges to diagnosis in order to promote safety.