{"id":5134,"date":"2017-01-09T16:27:00","date_gmt":"2017-01-09T16:27:00","guid":{"rendered":"https:\/\/www.thesullivangroup.com\/RSQSolutions\/?p=5134"},"modified":"2017-01-09T16:51:41","modified_gmt":"2017-01-09T16:51:41","slug":"cognitive-autopsy","status":"publish","type":"post","link":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/cognitive-autopsy\/","title":{"rendered":"The Cognitive Autopsy"},"content":{"rendered":"Ever since the Institute of Medicine\u2019s report To Err is Human was released in 2000, healthcare has seen a surge in patient safety initiatives. Analysis of medical errors has become increasingly widespread, with several different methods being used by hospitals and practitioners. Of these methods, I suggest that cognitive error analysis may prove to be one of the most valuable in determining the real underlying reasons for medical errors that lead to unexpected adverse patient outcomes.\nThe true origin of an adverse patient outcome may never be discovered for the simple reason that one key question was neither asked nor answered \u2013 \u201cWhat was the practitioner really thinking?\u201d Very often the answer is there, hidden in the decision-making area of the brain where the error truly began. Although it is not always possible to know the thought process behind every medical error, it is worth posing this question along with the other standard inquiries.\nIssues such as how clinical decisions are made, how they can lead to medical errors, and what can be done to prevent faulty decision-making have gained much attention in the medical literature of the past 15 years. The term cognitive autopsy appeared in the literature about a decade ago; it refers to the process of analyzing medical outcomes from the cognitive viewpoint. The practice of cognitive error analysis is another valuable weapon in the armamentarium of a patient safety program.\nSome of the popular methods of medical error analysis include:\n\nMorbidity and mortality conference\nMedical-legal analysis\nRoot cause analysis\nCognitive error analysis\n\nWhat is a Cognitive Autopsy?\nThe cognitive autopsy is a valuable tool, a newer method of error analysis defined as a \u201ccognitive root cause analysis of a medical event.\u201d Its purpose is to answer the key question, \u201cWhere did thinking and decision-making go wrong?\u201d The cognitive autopsy is also designed to provide meaningful, realistic self-feedback so that four things will happen:\n\nInsight will develop.\nLearning will occur.\nClinical cognition will change.\nThe adverse event will be less likely to happen again.\n\nHow is a Cognitive Autopsy Performed?\nThe process of a cognitive autopsy was outlined by Dr. William Croskerry more than 10 years ago. As soon as possible after you are aware that your patient has an unexpected adverse outcome, apply your knowledge of the CDRs (cognitive dispositions to respond) and ADRs (affective dispositions to respond) to analyze the event using the following guidelines:\n\nDo not discuss with others initially.\nComplete as soon as possible after the event.\nComplete when you are well rested.\nFind a quiet place.\nGo through the whole shift.\nFree-associate fully about the event. Recall thoughts and feelings.\nPlay close attention to ambient conditions.\nWrite down everything (however trivial).\nUse QA and Peer Review processes to discuss with others.\nUse a list to review the CDRs and ADRs.\nIdentify which CDRs and ADRs were involved and their impact.\n\nThis new tool of cognitive error analysis can be incorporated into an existing process such as a Morbidity and Mortality Conference, a Quality Assurance review, and Peer Review. You can participate in cognitive autopsies on cases involving other practitioners as long as there is enough detail and information available. Be sure to follow existing policies pertaining to confidentiality.\nThe following is a list of some of the more than 40 CDRs and ADRs that have been described; become familiar with and use this list as you perform cognitive autopsies.\n\nAnchoring\nAvailability\nCommission bias\nConfirmation bias\nDiagnostic momentum\nGambler\u2019s fallacy\nGender bias\nHindsight bias\nOmission bias\nOutcome bias\nOverconfidence bias\nPlaying the odds\nPosterior probability\nPremature closure\nRepresentativeness\nSearch satisficing\nZebra retreat\n\nA cognitive autopsy, despite the terminology, is not limited to cases where the outcome is fatal. Any case of unexpected adverse outcome with possible medical error is fair game for a cognitive autopsy.\nIn conclusion, a few quotes from baseball legend Yogi Berra that are germane to cognitive errors:\n\nWe made too many wrong mistakes.\nBaseball is ninety percent mental and the other half is physical.\nIf you ask me anything I don\u2019t know, I\u2019m not going to answer.\n\nReferences\n\nCroskerry P. Achilles heels of the ED: Delayed or Missed Diagnoses. ED Legal Letter. 2003;14:109-20.\nCroskerry P. Diagnostic Failure: A Cognitive and Affective Approach. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb.\nCroskerry P. The importance of cognitive errors in diagnosis and strategies to prevent them. Acad Med. 2003;78:1-6.\n\n","protected":false},"excerpt":{"rendered":"<p>Ever since the Institute of Medicine\u2019s report To Err is Human was released in 2000, healthcare has seen a surge in patient safety initiatives. Analysis of medical errors has become increasingly widespread, with several different methods being used by hospitals and practitioners. Of these methods, I suggest that cognitive error analysis may prove to be&#8230;<a class='learnmore' href='https:\/\/test.thesullivangroup.com\/RSQSolutions\/cognitive-autopsy\/'>Read More<\/a><\/p>\n","protected":false},"author":3,"featured_media":5137,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"om_disable_all_campaigns":false,"footnotes":""},"categories":[45,8,21,25],"tags":[],"acf":[],"_links":{"self":[{"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/posts\/5134"}],"collection":[{"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/comments?post=5134"}],"version-history":[{"count":7,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/posts\/5134\/revisions"}],"predecessor-version":[{"id":5191,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/posts\/5134\/revisions\/5191"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/media\/5137"}],"wp:attachment":[{"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/media?parent=5134"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/categories?post=5134"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/tags?post=5134"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}