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Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1998.
A report from a workshop, this document is a well-written look at the differences between "first stories" and "second stories" describing major errors. First stories are the easy one-person or one-cause accounts and reactions to critical incidents. "So-and-so forgot to check the patient's allergy history." Or "How could they have ignored the alarm and so many other red flags?" Even now, with some penetration of the concepts of systems thinking, it is still easy to fall back on the familiar and easy explanation of human error, missing key opportunities to fix underlying problems with processes of care or the way care is organized. Identifying such problems, however, requires the far richer "second stories" about such critical incidents, and these stories do not emerge without hard work. The authors have done this hard work for many publicized medical errors, drawing on follow-up newspaper articles and other investigative documents, often in far more obscure places than headlining first stories. Even readers familiar with root cause analysis will likely find value in many of the case studies. And, for those not familiar with such accident investigation techniques, the report provides a very readable introduction to their importance and a resource for further references.
Journal Article > Study
Feinstein AR, Niebyl JR. Arch Intern Med. 1971;128:774-780.
This study reports and analyzes findings of traditional clinicopathologic conferences (CPC) from Massachusetts General Hospital. By comparing the distribution of topics and the accuracy in making correct diagnoses over several decades, the authors explore one of the oldest forms of reasoning. The cases reviewed were classified both by clinical topic and error type to better understand the trends and patterns seen in diagnostic failures. The authors discuss the teaching role employed by CPC and the potential for computers to play an integral role in the diagnostic reasoning process.