Health Policy and Clinical Practice
Cognitive forcing strategies in clinical decisionmaking*,**,*

https://doi.org/10.1067/mem.2003.22Get rights and content

Abstract

Cognitive errors underlie most diagnostic errors that are made in the course of clinical decisionmaking in the emergency department. These errors are universal and are prevalent in the special milieu of the ED. Their properties appear to be distinct from those associated with the performance of procedures. They are often costly, but, importantly for both the patient and the physician, they are also highly preventable. Recent developments in education theory provide a means for minimizing and avoiding diagnostic error. Through the process of metacognition, clinicians can develop cognitive forcing strategies to abort such latent errors. Three levels of cognitive forcing strategies are described: universal, generic, and specific. Specific cognitive forcing strategies provide a formal cognitive debiasing approach to deal with what have previously been described as pitfalls in clinical reasoning. This metacognitive approach can be taught to practicing clinicians and to those in training to inoculate them against making diagnostic errors. The adoption of this method provides a systematic approach to cognitive root-cause analysis in the avoidance of adverse outcomes associated with delayed or missed diagnoses and with the clinical management of specific cases. [Ann Emerg Med. 2003;41:110-120.]

Introduction

Considerable attention has been directed recently toward the new science of error prevention in health care.1 A prerequisite to error prevention is an understanding of the nature of error processes. Over the past decade, each of the major benchmark studies2, 3, 4 that have looked at medical error included observations on characteristics of error in the emergency department. All showed a vulnerability to error in clinical decisionmaking, in which clinicians are required to integrate knowledge base with novel situations in reasoning through a diagnosis or management plan. Not surprisingly, the specialties in which diagnostic error was most prevalent were internal medicine, family medicine, and emergency medicine. Several studies indicate that diagnostic errors are among the most consequential of errors in the ED.5, 6 In a study of trauma resuscitation, reasoning errors were found in 100% of cases studied.7 Failure to diagnose accounted for approximately half of all closed claims in US EDs.8 Occasionally, inaccurate data, such as an aberrant laboratory value or a false-negative imaging study, might lead to diagnostic error, but it is clear that because the process of forming a diagnosis mostly depends on a clinician's thinking, the overwhelming majority must be a result of cognitive errors. A comprehensive overview of diagnostic error has recently been published.9 Such errors are largely preventable; however, there is very little helpful information in the description of an error as simply diagnostic. Like the Gordian knot, it should be unraveled to understand how it was put together. Thus, we need to start the process of dissecting diagnostic errors through cognitive root-cause analysis to understand their various and multiple causes. The purpose of this article is to shed some light on what underlies the pitfalls of diagnostic error and to offer strategies that minimize or prevent such error.

Section snippets

Cognitive error

Cognition is involved in all human behavior, from the simple skill-based levels through the higher-order, rule-based behaviors to the most complex level of cognition involved in knowledge-based behavior (Table 1).

. Levels of complexity of behavior.

LevelActivity
Skill basedWound repair, dislocation reduction, intubation
Rule basedRadiographic decision rules, clinical practice guidelines, algorithms
Knowledge basedClinical decisionmaking, management decisions, diagnostic reasoning
This is the 3-level

Metacognition

The concept of metacognition was introduced in the 1970s by Flavell25 and developed in the context of psychological education theory. Essentially, it means thinking about thinking. It describes an individual's ability to stand apart from his or her own thinking, to observe it, and to recognize opportunities for using interventional thinking strategies. It distinguishes adult from child thinking and the thinking of experts from that of nonexperts. Metacognition has been described as one of the

Cognitive forcing strategies

A prerequisite to minimizing or avoiding cognitive error is to develop a general working knowledge of cognitive error theory. Often, clinicians have little sensitivity, insight, or awareness of their own cognitive processes and, especially, of the considerable number of biases that might affect their thinking.17, 29 Traditional medical training has placed insufficient emphasis on this important aspect of clinical performance. The first step, then, is to develop an educational agenda for

Acknowledgements

I thank Calla Farn and Annette Murphy for their input on earlier versions of this manuscript, the anonymous reviewers for their comments and suggestions, and J. Frank Yates, PhD, Andrea Patalano, PhD, Larry Gruppen, PhD, and John Billi, MD, at the University of Michigan for their cooperation and assistance. The secretarial and administrative support of Sherri Lamont at the Department of Emergency Medicine at Dartmouth General Hospital is gratefully acknowledged.

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    *

    The Center for Safety in Emergency Care is a research consortium located at the University of Florida, Jacksonville, FL; Dalhousie University, Halifax, Nova Scotia, Canada; Northwestern University, Evanston, IL; and Brown University, Providence, RI.

    **

    The Center for Safety in Emergency Care is supported by a grant from the Agency for Healthcare Research and Quality (P2OHS11592-02).

    *

    Address for reprints: Pat Croskerry, MD, PhD, Department of Emergency Medicine, Capital Health/Dartmouth General Hospital Site, 325 Pleasant Street, Dartmouth, Nova Scotia, B2Y 4G8 Canada;,902-465-8491, fax 902-460-4148; E-mail [email protected]

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