Cognitive bias in clinical reasoning

2. Adverse events: 3,7% : 14% deaths 27% malpractice: 75% diagnostic problem.

3. Most common medical errors

5. System and Diagnosis An 35 y/o man went to ED Referring back pain and paraparesia He went twice to the ED. No one asked.. And couldn,t retrieve medical record At that moment was impossible to track a diagnosis of melanoma two years before Doctor´s mind: a young Person can,t have An important disease SYSTEM Cognitive

6. JAMA Volume 301(10) March 11, 2009 Copyright 2009 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use. American Medical Association, 515 N. State St, Chicago, IL 60610. ISSN: 0098-7484

8. Diagnostic error compound

9. More automatic: More experience More analysis Slower Less experience Wrong mental reasoning Lack of Information. Rethinking Two Systems of reasoning (Croskerry)

10. Examples of Cognitive errors (heuristics) Next cartoons extracted from: Sox. Clinical Decision Making. Butterworth-Heineman 1988.

11. Representation heuristics Endocrinologist think About Cushing in a patient with high BP and hirsutism (non prevalent)

12. Availability The intern saw two Splenic abscess in the previous rotation. Now he thinks that there is another one in front Of him.

13. Premature closing I don,t have the biopsy but anyway, he just came with fever.

14. Overconfidence

15. Framing: to put labels on people

18. Retroperitoneal Hematoma Hb 13/5/08 19 18/05 17,5 19/05 16,5 21/05 15 22/05/10 14,5 System Failure:”: Communicatión Organizatión informatión

20. Pancoast tumor : 5% lung cancer Horner Syndrom: 14-50% of cases. Framing : old people felt down .. Because they felt down Premature closing : no one examine the information about the previous diagnosis.

22. Fish bone diagram to study the systems aspects related to diagnosis FAILURE TEAM Communicatión Coordinatión Training PROCESS Not specified Lack of material No supervisión Bad asignament Wrong test ROLES Wrong evaluation of urgency Complications No alerts Inefficient summary of data COGNITIVE COMPOUND

23. (Checklist) Dr. M. Graber

24. IMPROVEMENT AND CHANGE IS POSSIBLE