Summary
This study identified 100 cases of diagnostic error in internal medicine and conducted retrospective chart reviews and interviews to determine what role systems-related and cognitive factors played. Investigators discovered nearly six independent factors per case and provide a detailed discussion of the most common findings. These include system-related problems such as inefficient processes and cognitive problems such as failure to consider alternative clinical diagnoses. The authors propose a classification system for the factors that produce errors and offer a number of strategies to reduce their incidence.
The PSNet collection materials were developed with funding under multiple contracts from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.