The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.

Trauma patients, who often suffer multiple, severe injuries and who may arrive to the Emergency Department (ED) unconscious, are vulnerable to adverse events. Using data reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers in this study evaluated the safety challenges of caring for patients presenting to the ED after a motor vehicle collision. Common challenges included issues with monitoring, treatment, evaluation, and/or documentation, patient falls, medication errors, and problems with transfers.

Efforts to reduce diagnostic error should include educational strategies for improving diagnosis. This article describes the development of a learning health system around diagnostic safety at one large, integrated health care system. The program identified missed opportunities in diagnosis based on clinician reports, patient complaints, and risk management, and used trained facilitators to provide feedback to clinicians about these missed opportunities as learning opportunities. Both facilitators and recipients found the program to be useful and believed it would improve future diagnostic safety. 

This retrospective cohort study used root cause analysis (RCA) to examine safety reports from emergency departments at Veterans Health Administration hospitals over a two-year period. Of the 144 cases identified, the majority involved delays in care (26%), elopements (15%), suicide attempts and deaths (10%), inappropriate discharges (10%) and errors following procedures (10%). RCA revealed that primary contributory factors leading to adverse events were knowledge/educational deficits (11%) and policies/procedures that were either inadequate (11%) or lacking standardization (10%).

The hectic pace of emergency care detracts from reliability. This review examined the literature on evidence, practice, and patient perspectives regarding diagnostic error in the emergency room. A WebM&M commentary discussed an incident involving a diagnostic delay in the emergency department.

Reducing the number of alarms can help alleviate alarm fatigue and the associated patient safety hazards. In this study, researchers successfully implemented a number of interventions which led to a 61% decrease in average alarms per monitored bed in a cardiovascular surgical intensive care unit and a reduction in cardiorespiratory events.

A protocolized early warning system to improve sepsis recognition and management was associated with a decrease in sepsis-related inpatient mortality. The protocol emphasized early recognition by nurses and escalation of care by a nurse practitioner when indicated. An AHRQ WebM&M commentary describes common errors in the early management of sepsis.

This systematic review found that equipment and procedural distractions were the most severe distraction events during surgery, but irrelevant conversation and movement were the most frequent. This underscores the need to reduce distractions and incorporate management of distractions into surgical education.

Simulation training has been used to improve patient safety across multiple care settings. This study sought to enhance diagnostic accuracy for trauma care among resident-level trainees. Researchers developed several standardized cases to assess care for a patient presenting with severe injury. Some scenarios were algorithmic and others required more analysis. Residents with more years of training performed better on the simpler scenarios but worse on the analytic scenarios which required that they reassess their diagnosis. This finding suggests that those with more experience assimilated the algorithms more readily, but they also continue to need cognitive training for diagnostic accuracy. A past AHRQ WebM&M interview with Dr. Pat Croskerry discusses the need to enhance cognitive skills for diagnosis in medical training.

This study used written medical cases to examine whether simulated time pressure or interruptions affect diagnostic accuracy among resident and attending emergency medicine physicians. While the experienced physicians answered the questions more quickly and accurately compared to resident physicians, diagnostic accuracy was not compromised by time pressure or interruptions for either group in this study.

Residents and fellows frequently failed to identify serious clinical abnormalities when asked to review the electronic medical record (EMR) of a simulated intensive care unit patient, indicating that the design of the EMR may affect situational awareness.

This commentary highlights the need to evaluate diagnostic reasoning in emergency medicine to address gaps and motivate research exploring factors that impair assessment.

In this study involving surgical residents, the introduction of realistic interruptions and distractions into simulated surgical scenarios resulted in a significantly higher incidence of technical errors during the procedures.

This research letter examines the value of the physical examination in forming a correct diagnosis on admission. The authors found that four out of five internal medicine patients in the emergency department could be correctly diagnosed from information gleaned by the history, physical examination, and basic laboratory tests.

This study found that only 3% of radiographs were misinterpreted by emergency physicians on a subsequent interpretation by a radiology attending. The most commonly missed findings included fractures, dislocations, and pulmonary nodules. A past AHRQ WebM&M commentary discussed radiographic errors in the emergency department.

Diagnostic errors are frequently ascribed to cognitive errors on the part of clinicians. Prominent among these is availability bias, when clinicians choose the most available diagnosis—the first that comes to mind—when faced with a complex diagnostic scenario. In this Dutch study, internal medicine residents were presented with a series of diagnosed cases, then given cases with similar symptoms and asked to record their provisional diagnoses. The investigators did find evidence of availability bias, but also found that asking residents to reflect on their diagnostic process mitigated the effects of availability bias. Diagnostic errors have been termed the next frontier in patient safety, and an AHRQ WebM&M commentary discusses reflective practice and other methods of avoiding cognitive error in diagnosis.

A decision support program improved adherence to recommended diagnostic algorithms for common emergency department conditions.