What makes diagnosis hard?
- 417 Downloads
This essay uses a case study to explore some of the reasons why understanding failures associated with diagnosis seems to have lagged behind the attention and understanding directed at failures in other aspects of healthcare (e.g., wrong patient/procedure, medication misadministration, etc). The goal is not to pose an alternative to many of the current ideas about problems in diagnosis, but rather to enrich the discussions.
KeywordsCognition Hindsight bias Joint cognitive systems Mis-diagnosis Sense-making Patient safety
- Brehmer, B. (1987). Development of mental models for decision in technological systems. In J. Rasmussen, K. Duncan, & J. Leplat (Eds.), New technology and human error (pp. 111–120). Chichester, UK: Wiley.Google Scholar
- Henriksen, K., & Kaplan, H. (2003). Hindsight bias, outcome knowledge and adaptive learning. Quality and Safety in Health Care, 12(Suppl 2), ii46–ii50.Google Scholar
- Hollnagel, E., & Woods, D. D. (2006). Joint cognitive systems: Foundations of cognitive systems engineering. Boca Raton, FL: CRC Press/Taylor & Francis Group.Google Scholar
- Hutchins, E. (1996). Cognition in the wild. Cambridge, MA: MIT Press.Google Scholar
- Norman, G., Young, M., & Brooks, L. (2007). Non-analytical models of clinical reasoning: The role of experience. Medical Education, 41(12), 1140–1145.Google Scholar
- Raiffa, H. (1970). Decision analysis: Introductory Lectures on choices under uncertainty. Reading, MA: Addison-Wesley.Google Scholar
- Rudolph, J. W., Morrison, J. B., & Carroll, J. S. (2009, in press). The dynamics of diagnosing: action-oriented problem solving in fast-paced, high-stakes settings. Academy of Management Review, 34(4).Google Scholar
- Vicente, K. J. (1999). Cognitive work analysis. Mahwah, NJ: Lawrence Erlbaum Associates.Google Scholar
- Weick, K. E. (1995). Sense making in organizations. Thousand Oaks, CA: Sage.Google Scholar
- Woods, D. D., & Hollnagel, E. (2006). Joint cognitive systems: Patterns in cognitive systems engineering. Boca Raton, FL: CRC Press/Taylor & Francis Group.Google Scholar