Diagnostic Errors in Medicine: A Case of Neglect

Cabot, 1912, Diagnostic pitfalls identified during a study of three thousand autopsies, JAMA, 59, 2295, 10.1001/jama.1912.04270130001001

Gore, 2003, Historical perspective on medical errors: Richard Cabot and the Institute of Medicine, J Am Coll Surg, 197, 609, 10.1016/S1072-7515(03)00672-0

Croftan, 1913, The diagnostic doubts of Dr. Cabot, JAMA, 60, 145, 10.1001/jama.1913.04340020053021

Graber, 2002, Reducing diagnostic error in medicine: What’s the goal?, Acad Med, 77, 981, 10.1097/00001888-200210000-00009

Kuhn, 2002, Diagnostic errors, Acad Emerg Med, 9, 740, 10.1197/aemj.9.7.740

Croskerry, 2003, The importance of cognitive errors in diagnosis and strategies to minimize them, Acad Med, 78, 775, 10.1097/00001888-200308000-00003

Foucar, 2000, Error in anatomic pathology

Fitzgerald, 2001, Error in Radiology, Clin Radiol, 56, 938, 10.1053/crad.2001.0858

O’Connor, 1995, Unnecessary delays in accident and emergency departments: Do medical and surgical senior house officers need to vet admissions?, J Accid Emerg Med, 12, 251, 10.1136/emj.12.4.251

Gorter, 2002, Psoriatic arthritis: Performance of rheumatologists in daily practice, Ann Rheum Dis, 61, 219, 10.1136/ard.61.3.219

Christensen-Szalinski, 1981, Physicians’ use of probabalistic information in a real clinical setting, J Exp Psychol Hum Percept Perform, 7, 928, 10.1037/0096-1523.7.4.928

Margo, 2003, A pilot study in ophthalmology of inter-rater related reliability in classifying diagnostic errors: An under-investigated area of medical error, Qual Saf Health Care, 12, 416, 10.1136/qhc.12.6.416

Beam, 1996, Variability in the interpretation of screening mammograms by US radiologists: Findings from a national sample, Arch Intern Med, 156, 209, 10.1001/archinte.1996.00440020119016

Hoffman, 1968, An analysis-of-variance model for the assessment of configural cue utilization in clinical judgment, Psychol Bull, 69, 338, 10.1037/h0025665

Wu, 1991, Do house officers learn from their mistakes?, JAMA, 265, 2089, 10.1001/jama.1991.03460160067031

Leape, 1991, The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study II, N Engl J Med, 324, 377, 10.1056/NEJM199102073240605

Shojania, 2003, Changes in rates of autopsy-detected diagnostic errors over time, JAMA, 289, 2849, 10.1001/jama.289.21.2849

The Autopsy as an Outcome and Performance Measure. Evidence report/Technology assessment #58. AHRQ Publication No 03-E002. Agency for Healthcare Research and Quality, Rockville, MD, 2003.

Berwick, 2003, Errors today and errors tomorrow, N Engl J Med, 348, 2570, 10.1056/NEJMe030044

Kassirer, 1989, Diagnostic reasoning, Ann Intern Med, 110, 893, 10.7326/0003-4819-110-11-893

Elstein, 1995, Clinical reasoning in medicine, 49

Croskerry, 2000, The cognitive imperative: Thinking about how we think, Acad Emerg Med, 7, 1223, 10.1111/j.1553-2712.2000.tb00467.x

Croskerry, 2003, Safety errors in emergency medicine, 29

Weeks, 2001, Tort claims analysis in the Veterans Health Administration for quality improvement, J Law Med Ethics, 29, 335, 10.1111/j.1748-720X.2001.tb00352.x

Bartlett, 1998, Physicians’ cognitive errors and their liability consequences, J Healthc Risk Manag, 18, 62, 10.1002/jhrm.5600180407

Adams, 2000, System contributions to error, Acad Emerg Med, 7, 1189, 10.1111/j.1553-2712.2000.tb00463.x

M.L. Graber, et al.: Diagnostic error in internal medicine. Poster presented at the National Patient Safety Foundation Annual Meeting, Boston, May 3–7, 2004.

Joint Commission on Accreditation of Healthcare Organizations: Reporting of Medical/Health Care Errors. A position statement of the Joint Commission on Accreditation of Healthcare Organizations. Nov. 8, 2003.

2002

The Leapfrog Group for Patient Safety. http://www.leapfroggroup.org (last accessed Dec. 8, 2004).

K.G. Shojania, et al.: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 from the Agency for Healthcare Research and Quality: AHRQ Publication No. 01-E058. Rockville, MD, 2001. http://www.ahrq.gov/clinic/ptsafety/ (last accessed Dec. 8, 2004).

Anderson, 1999, Billions for defense: The pervasive nature of defensive medicine, Arch Intern Med, 159, 2399, 10.1001/archinte.159.20.2399

Kessler, 1996, Do doctors practice defensive medicine?, Q J Econ, 111, 353, 10.2307/2946682

Kessler, 2002, How liability law affects medical productivity, J Health Econ, 21, 931, 10.1016/S0167-6296(02)00076-0

Blendon, 2002, Views of practicing physicians and the public on medical errors, N Engl J Med, 347, 1933, 10.1056/NEJMsa022151

Croskerry, 2000, The feedback sanction, Acad Emerg Med, 7, 1232, 10.1111/j.1553-2712.2000.tb00468.x

Parker, 2003, Psychological contribution to the understanding of adverse events in health care, Qual Saf Health Care, 12, 453, 10.1136/qhc.12.6.453

Sporer, 1995, Choosing, confidence, and accuracy: A meta-analysis of the confidence-accuracy relation in eyewitness identification studies, Psychol Bulletin, 118, 315, 10.1037/0033-2909.118.3.315

Reason, 1990, Errors and violation on the roads: A real distinction?, Ergonomics, 33, 1315, 10.1080/00140139008925335

Russo, 1989

Kruger, 1999, Unskilled and unaware of it: How difficulties in recognizing one’s own incompetence lead to inflated self-assessments, J Pers Soc Psychol, 77, 1121, 10.1037/0022-3514.77.6.1121

Hodges, 2001, Difficulties in recognizing one’s own incompetence: Novice physicians who are unskilled and unaware of it, Acad Med, 76, S87, 10.1097/00001888-200110001-00029

Hall, 2003, Surgeons and cognitive processes, Br J Surg, 90, 10, 10.1002/bjs.4020

Gawande, 2001, Final cut: Medical arrogance and the decline of the autopsy, The New Yorker, 19, 94

K.G. Shojania: Diagnostic surprises and the persistent value of the autopsy. AHRQ Web M&M 2004. http://webmm.ahrq.gov/cases.aspx?ic=54 (last accessed Dec. 8, 2004).

Podbregar, 2001, Should we confirm our clinical diagnostic certainty by autopsies?, Intensive Care Med, 27, 1750, 10.1007/s00134-001-1129-x

Croskerry, 2002, Achieving quality in clinical decision making: Cognitive strategies and detection of bias, Acad Emerg Med, 9, 1184, 10.1197/aemj.9.11.1184

Cosby, 2003, Patient safety: A curriculum for teaching patient safety in emergency medicine, Acad Emerg Med, 10, 69, 10.1197/aemj.10.1.69

Schiff, 2004

Nolan, 2000, System changes to improve patient safety, BMJ, 320, 771, 10.1136/bmj.320.7237.771

Joint Commission on Accreditation of Healthcare Organizations: 2005 Laboratory Service National Patient Safety Goals. http://www.jcaho.org/accredited+organizations/patient+safety/05+npsg/05_npsg_lab.htm (last accessed Dec. 8, 2004).

Hunt, 1998, Effects of computer-based clinical decision support systems on physician performance and patient outcomes: A systematic review, JAMA, 280, 1339, 10.1001/jama.280.15.1339

Trowbridge R., Weingarten S.: Clinical decision support systems. In: Shojania K.G., et al. (eds.): Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 from the Agency for Healthcare Research and Quality: AHRQ Publication No. 01-E058. Rockville, MD, 2001. http://www.ahrq.gov/clinic/ptsafety/ (last accessed Dec. 8, 2004).

Espinosa, 2000, Reducing errors made by emergency physicians in interpreting radiographs: Longitudinal study, BMJ, 320, 737, 10.1136/bmj.320.7237.737

Kripalani S., et al.: Reducing errors in the interpretation of plain radiographs and computed tomography scans. In: Shojania K.G., et al. (eds.): Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 from the Agency for Healthcare Research and Quality: AHRQ Publication No. 01-E058. Rockville, MD, 2001. http://www.ahrq.gov/clinic/ptsafety/ (last accessed Dec. 8, 2004).

Westra, 2002, The impact of second opinion surgical pathology on the practice of head and neck surgery: A decade experience at a large referral hospital, Head and Neck, 24, 684, 10.1002/hed.10105

Ruchlin, 1982, The efficiency of second-opinion consultation programs: A cost-benefit perspective, Med Care, 20, 3, 10.1097/00005650-198201000-00002

Croskerry, 2003, Cognitive forcing strategies in clinical decision making, Ann Emerg Med, 41, 110, 10.1067/mem.2003.22

Balzer, 1989, Effects of cognitive feedback on performance, Psychol Bull, 106, 410, 10.1037/0033-2909.106.3.410

Smith-Bindman, 2003, Comparison of screening mammography in the United States and the United Kingdom, JAMA, 290, 2129, 10.1001/jama.290.16.2129

Hill, 1988

Lundberg, 1998, Low-tech autopsies in the era of high-tech medicine: Continued value for quality assurance and patient safety, JAMA, 280, 1273, 10.1001/jama.280.14.1273

Patriquin, 2001, Postmortem whole-body magnetic resonance imaging as an adjunct to autopsy: Preliminary clinical experience, J Magn Reson Imaging, 13, 277, 10.1002/1522-2586(200102)13:2<277::AID-JMRI1040>3.0.CO;2-W

Pierluissi, 2003, Discussion of medical errors in morbidity and mortality conferences, JAMA, 290, 2838, 10.1001/jama.290.21.2838

Agency for Healthcare Quality and Research: Welcome to AHRQ Web M&M. http://webmm.ahrq.gov/default.aspx. (last accessed Dec. 8, 2004)

Kirch, 1996, Misdiagnosis at a university hospital in 4 medical eras, Medicine (Baltimore), 75, 29, 10.1097/00005792-199601000-00004

Silver N., Wooner K.: QuesTec not yet showing consistency from umpires. ESPN Baseball. Jun. 5, 2003.

Maguire, 2003, Is an access crisis on the horizon in mammography?, ACP Observer, 23, 1