Background: Diagnostic error in medicine is increasingly recognized as “the next frontier for patient safety”. Current research has explored the etiologies of diagnostic errors in two unique dimensions: as systems-based or cognitive-based causes. One study, however, suggests that roughly half of all errors stem from both domains. Using a focused ethnographic approach, we sought to understand how systems-based factors may contribute to cognitive missteps underlying diagnostic error.
Methods: We conducted a focused ethnography of inpatient medicine teaching teams at two affiliated academic institutions. Teams (each consisting of 1 attending, 1 senior resident, 2-3 interns, and 1-4 medical students) were observed on rounds as well as during post-round work. Field notes related to the diagnostic process as well as the work system were recorded and collated. Observations were followed by focus groups with residents and interns and interviews with attending physicians, to better understand perceptions around diagnosis and factors contributing to error. Inductive analysis was used to organize findings into themes, which were then categorized according to a previously described taxonomy into systems-factors contributing to the cognitive domains of faulty data gathering, faulty information processing, and faulty data verification. An additional category describing work environment factors encompassing all of these cognitive domains was added.
Results: Between January 2016 and April 2017, 10 teams were observed over the course of 286 hours. All 10 attending physicians and 31 interns and residents attended interviews or focus groups. The following key themes that bridged system and cognitive factors were identified. First, challenges with interdisciplinary communication, particularly in-person communication with nursing, as well as closed-loop communication within the electronic medical record (EMR) were felt to contribute to faulty data gathering. Second, information contained within the EMR was often viewed as unreliable and inaccessible due to poor integration and interface. Third, organizational structures such as the operation of consulting services in silos and the reliance on inexperienced overnight radiology reads were felt to contribute to faulty information processing. Fourth, frequent care handoffs, between outgoing and oncoming providers as well as the emergency department and the inpatient ward, were noted to provide opportunities for faulty data verification. Finally, interruptions, time constraints, and a cluttered physical environment were found to adversely impact all cognitive domains.
Conclusions: Systems-based and cognitive factors may occur simultaneously in diagnostic errors. Interventions aimed at addressing cognitive contributions should be coupled with systems-based interventions in order to maximize effectiveness.