Front cover image for The cognitive autopsy : a root cause analysis of medical decision making

The cognitive autopsy : a root cause analysis of medical decision making

Pat Croskerry (Author)
"If you wish to visit a new place, help is available everywhere: maps, guide books, Internet sites for trip planning, online reviews and personal advice etc. But nothing beats finding a local guide, someone who lives there, and knows the land, its people, culture and "how things work here".That's exactly the role that Pat Croskerry plays in The Cognitive Autopsy - he's our guide to the still-emerging arena of understanding diagnostic error. Pat has spent a long career working on the front lines in emergency medicine, also known as the emergency room (ER) or the emergency department (ED). Pat knows this place like the back of his hand, and is the perfect person to show us around, and orientate us to what there is to see.The Cognitive Autopsy is a unique and fascinating collection of cases that span the spectrum of diagnostic error types and causes seen in the ED. Each one is its own self-contained story, with lessons of cognitive and affective biases. Stories are powerful, and it is said that stories may be how our knowledge base is organized. A diagnosis is itself a story - the medical story that corresponds to and flows from the patient's story"-- Provided by publisher
Print Book, English, 2020
Oxford University Press, New York, NY, 2020
Case Reports
xi, 325 pages : illustrations (chiefly color) ; 26 cm
9780190088743, 0190088745
ForewordPrefaceAcknowledgementsIntroductionThe CasesCase 1. Christmas SurprisesCase 2. Distraught DistractionCase 3. The Fortunate FootballerCase 4. An Incommoded Interior DesignerCase 5. Teenage TachypnoeaCase 6. The Backed-up Bed BlockerCase 7. The English PatientCase 8. Lazarus ReduxCase 9. A Model PilotCase 10. A Rash DiagnosisCase 11. The Perfect StormCase 12. A Case of Premature ClosureCase 13. Postpartum PuzzlerCase 14. The Blind Leading the BlindableCase 15. Pseudodiagnosis of PseudoseizureCase 16. Failed Frequent Flyers (a and b)Case 17. Explosions, Expletives and Erroneous ExplanationsCase 18. The Representativeness RepresentativeCase 19. The Michelin LadyCase 20. An Instable InadvertenceCase 21. A Laconic LadCase 22. The Misunderstood MatelotCase 23. A Hard Tale to SwallowCase 24. A Rake's ProgressCase 25. Deceptive DetachmentCase 26. A Search Satisfied SkateboarderCase 27. The Vacillated VagrantCase 28. A Tale of Two Cycles (a and b)Case 29. Misleading MydriasisCase 30. Bungled BullaeCase 31. Overdosing the OverdosedCase 32. The Lost GuideCase 33. Hazardous HandoverCase 34. Double TroubleCase 35. Tracking Fast and SlowCase 36. Alternate AlternativesCase 37. Notable Near-missCase 38. A Stone Left UnturnedCase 39. Sweet NothingsCase 40. Straining the Strain DiagnosisCase 41. Missed ItConclusion: Strategies for Improving Clinical Decision MakingAppendix A: Diagnoses in 42 CasesAppendix B: Probable Biases and Their Frequencies in 42 Clinical CasesAppendix C: Analysis of Ordinal Position of Bias in Clinical CasesAppendix D: Potential Error-Producing ConditionsAppendix E: Analysis of Knowledge-Based Errors in the Case SeriesGlossary of Biases and Their Cognitive FactorsIndex