Fatal flaws in clinical decision making.
Clinical decision-making is a complex process affected by many factors and has important implications for patient outcomes. Using data from the Australian and New Zealand Audit of Surgical Mortality database over a 1-year period, researchers fully audited 3422 deaths and identified 226 cases involving a clinical decision-making incident (CDMI) thought to be concerning by reviewers. The most frequently noted incident was decision to operate, followed by diagnostic error and insufficient postoperative evaluation. The authors suggest that thorough discussion of complex cases in advance of surgery might mitigate CDMIs related to decisions to perform surgery and that retrospectively reviewing deaths for such CDMIs may supplement existing processes for reviewing and learning from surgical mortality. A WebM&M commentary discussed an incident involving a diagnostic error in which a patient was taken to the operating room for an unnecessary surgery.