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  • The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making

    The Cognitive Autopsy by Croskerry, Pat;

    A Root Cause Analysis of Medical Decision Making

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    A termék adatai:

    • Kiadó OUP USA
    • Megjelenés dátuma 2020. július 24.

    • ISBN 9780190088743
    • Kötéstípus Puhakötés
    • Terjedelem344 oldal
    • Méret 251x175x17 mm
    • Súly 703 g
    • Nyelv angol
    • 6

    Kategóriák

    Rövid leírás:

    Recently, it has become clear that medical error is a leading cause of death, and one of the biggest problems occurs when doctors get the diagnosis wrong. Typically, patients may feel that their diagnosis was delayed or wrong because the doctor didn't know enough about their disease, but many studies now show that the problem is more likely to be a failure in how doctors think rather than in what they don't know. This book offers some insight into how doctors think. It identifies a number of biases in medical decision making that are largely responsible for diagnoses being delayed or missed.

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    Hosszú leírás:

    Behind heart disease and cancer, medical error is now listed as one of the leading causes of death. Of the many medical errors that may lead to injury and death, diagnostic failure is regarded as the most significant. Generally, the majority of diagnostic failures are attributed to the clinicians directly involved with the patient, and to a lesser extent, the system in which they work. In turn, the majority of errors made by clinicians are due to decision making failures manifested by various departures from rationality. Of all the medical environments in which patients are seen and diagnosed, the emergency department is the most challenging. It has been described as a "wicked" environment where illness and disease may range from minor ailments and complaints to severe, life-threatening disorders.

    The Cognitive Autopsy is a novel strategy towards understanding medical error and diagnostic failure in 42 clinical cases with which the author was directly involved or became aware of at the time. Essentially, it describes a cognitive approach towards root cause analysis of medical adverse events or near misses. Whereas root cause analysis typically focuses on the observable and measurable aspects of adverse events, the cognitive autopsy attempts to identify covert cognitive processes that may have contributed to outcomes. In this clinical setting, no cognitive process is directly observable but must be inferred from the behavior of the individual clinician. The book illustrates unequivocally that chief among these cognitive processes are cognitive biases and other flaws in decision making, rather than knowledge deficits.

    This is the first book I have read that uses actual patient care cases to investigate medical decisions that lead to errors and eventually unexpected outcomes. The depth of the discussion in these cases leaves readers with a good understanding of the processes that lead to the outcomes.

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    Tartalomjegyzék:

    Foreword
    Preface
    Acknowledgements
    Introduction
    The Cases
    Case 1. Christmas Surprises
    Case 2. Distraught Distraction
    Case 3. The Fortunate Footballer
    Case 4. An Incommoded Interior Designer
    Case 5. Teenage Tachypnoea
    Case 6. The Backed-up Bed Blocker
    Case 7. The English Patient
    Case 8. Lazarus Redux
    Case 9. A Model Pilot
    Case 10. A Rash Diagnosis
    Case 11. The Perfect Storm
    Case 12. A Case of Premature Closure
    Case 13. Postpartum Puzzler
    Case 14. The Blind Leading the Blindable
    Case 15. Pseudodiagnosis of Pseudoseizure
    Case 16. Failed Frequent Flyers (a and b)
    Case 17. Explosions, Expletives and Erroneous Explanations
    Case 18. The Representativeness Representative
    Case 19. The Michelin Lady
    Case 20. An Instable Inadvertence
    Case 21. A Laconic Lad
    Case 22. The Misunderstood Matelot
    Case 23. A Hard Tale to Swallow
    Case 24. A Rake's Progress
    Case 25. Deceptive Detachment
    Case 26. A Search Satisfied Skateboarder
    Case 27. The Vacillated Vagrant
    Case 28. A Tale of Two Cycles (a and b)
    Case 29. Misleading Mydriasis
    Case 30. Bungled Bullae
    Case 31. Overdosing the Overdosed
    Case 32. The Lost Guide
    Case 33. Hazardous Handover
    Case 34. Double Trouble
    Case 35. Tracking Fast and Slow
    Case 36. Alternate Alternatives
    Case 37. Notable Near-miss
    Case 38. A Stone Left Unturned
    Case 39. Sweet Nothings
    Case 40. Straining the Strain Diagnosis
    Case 41. Missed It
    Conclusion: Strategies for Improving Clinical Decision Making
    Appendix A: Diagnoses in 42 Cases
    Appendix B: Probable Biases and Their Frequencies in 42 Clinical Cases
    Appendix C: Analysis of Ordinal Position of Bias in Clinical Cases
    Appendix D: Potential Error-Producing Conditions
    Appendix E: Analysis of Knowledge-Based Errors in the Case Series
    Glossary of Biases and Their Cognitive Factors
    Index

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