Medical Error Avoidance Workshop – Further Reading List: Papers
Links to papers are at www.jround.co.uk/error
• Citation classics in patient safety research
Lilford, R., Stirling, S. & Maillard, N. (2006) Citation classics in patient safety research: an invitation to contribute to an online bibliography. Quality and Safety in Health Care, 15 (5), 311-313.
A review of the most influential patient safety articles with papers ranging from 1975 to 2000. This gives a good short summary table of the top 10 highest cited papers and therefore is a good place to start to understand the background literature.
• A cognitive taxonomy of medical errors
Zhang, Jiajie, Patel, Vimla L., Johnson, Todd R. & Shortliffe, Edward H. (2004) A cognitive taxonomy of medical errors. Journal of Biomedical Informatics, 37 (3), 193-204.
This paper tries to categorise medical errors by using cognitive theories of human error and then giving examples of medical error cases to fit each category. It aims to identify cognitive mechanisms in an attempt to develop interventions to decrease medical errors. It categorises the major types of error into ‘slips’ and ‘mistakes’ which are then subdivided and explored.
• The importance of cognitive errors in diagnosis and strategies to minimize them
Croskerry, Pat. (2003) The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78 (8), 775-780.
This concentrates on cognitive errors such as those associated with failures in perception, failed heuristics and biases, referred to as ‘Cognitive Dispositions to Respond’. It describes strategies to reduce these errors which are described as ‘Cognitive Debiasing’ strategies.
• Human error: models and management
Reason, James. (2000) Human error: models and management. BMJ, 320 (7237), 768-770.
This paper explains the System versus Person approach to human error including Reasons Swiss cheese model.
• Clinical cognition and diagnostic error: applications of a dual process model of reasoning
Croskerry, Pat. (2009) Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv in Health Sci Educ (2009) 14:27-35.
A discussion of the two main approaches in decision making: the intuitive (system1) and the analytical (system 2), and a model of how these two different processes interact as clinicians attempt to make a diagnosis.
• Relating faults in Diagnostic Reasoning with Diagnostic Errors and Patient Harm
Zwaan, Laura. (2012) Relating faults in diagnostic reasoning with Diagnostic errors and patient harm. Academic Medicine, Vol 87, No.2, 149-156.
Retrospective review looking at Suboptimal Cognitive Acts (SCA), i.e. faults in diagnostic reasoning and subsequent errors and patient harm. A commentary by Schiff et al p135-138 in the same edition of Academic Medicine discusses checklists as an intervention to try to reduce diagnostic errors. (How can we make diagnosis safer?)
Medical Error Avoidance Workshop – Further reading list – Books
The Checklist Manifesto: How to get things right - Atul Gawande
Surgeon and writer Atul Gawande discusses how the practice of medicine has become increasingly complex and therefore prone to error. He provides the background for the development of a checklist which, applied around the world, has had an impressive impact on patient safety.
Psychologist Daniel Kahneman explores many of the heuristics and biases that affect our thinking and decision making and how they lead to error.