Use of a novel, modified fishbone diagram to analyze diagnostic errors

Abstract

Diagnostic errors comprise a critical subset of medical errors and often stem from errors in individual cognition. While traditional patient safety methods for dissecting medical errors focus on faulty systems, such methods are often less useful in cases of diagnostic error, and a broader cognitive framework is needed to ensure a comprehensive analysis of these complex events. The fishbone diagram is a widely utilized patient safety tool that helps to facilitate root cause analysis discussions. This tool was expanded by the authors to reflect the contributions of both systems and individual cognitive errors to diagnostic errors. We describe how two medical centers have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets the patient safety and educational needs of their respective institutions.

Operational measurement of diagnostic safety: state of the science

“…Other factors related to diagnostic error, such as the presence of patient harm (e.g., clear evidence of harm versus "near-misses"), preventability, and actionability, may also be important to define in advance so that the selected measurement strategy aligns with the learning and improvement goals. Nevertheless, the science of understanding the complex mix of cognitive and sociotechnical contributory factors and implementing effective solutions based on these data still needs additional development [100][101][102].…”

Diagnostic error: incidence, impacts, causes and preventive strategies

“…45 Rushed clinical handovers, heavy caseloads, distractions and interruptions, caring for critically ill or complex multimorbid patients, interactions with uncooperative or non-communicative patients, and clinician fatigue or personal stressors are some examples. 46 Computer-assisted diagnosis in various forms can improve diagnostic performance. Computed decision support systems that generate differential diagnoses using inputted clinical data yield small improvements in diagnostic accuracy when clinicians revisit their diagnoses following a differential diagnosis generator consultation.…”

Feasibility and Reliability Testing of Manual Electronic Health Record Reviews as a Tool for Timely Identification of Diagnostic Error in Patients at Risk

“…[6][7][8] The multiple factors that cause DEs range from cognitive failures on the part of individuals, including diagnosing clinicians, system failures for tracking and managing test results, and poor teamwork and communication. [9][10][11][12] Despite the importance of DE, the process of reporting errors and near misses remains underdeveloped and lacks standardized measurement tools. 13,14 DEs more often result in death and are the leading cause of claims-associated death and disability; indeed, until a decade ago, much of what was known about DE was learned through the evaluation of data from malpractice claims.…”