Potential Cognitive Processing Error1,2
Patient is an infant seen in the ED [emergency department] during high flu season after an episode of vomiting and period of apnea observed by family. Was discharged, but returned later. Family reported that the patient had another episode of apnea. Patient was evaluated and transferred to another facility for clinical impression of apnea and reflux.
Availability heuristic. The tendency to accept a diagnosis based upon recent or vividly recalled cases or events rather than on prevalence or probability.
Authority report stated missed diagnosis of apnea and reflux. Physician potentially attributed symptoms to common flu, due to availability. A more thorough physical examination may have led to the discovery of other symptoms indicative of apnea and reflux.
Patient seen in the ED on day one and day two for complaints of shortness of breath and chest pain. Diagnosed with an upper respiratory infection and sent home each time. Subsequently later admitted and died. Coroner preliminary report indicated PE [pulmonary embolus] as cause of death.
Anchoring heuristic. The tendency to fixate on first impressions or initial symptoms without considering causes that appear later or those that do not support the initial hypothesis or diagnosis.
Authority report stated missed diagnosis of PE. Physician may have anchored on diagnosis "upper respiratory infection." Once a physician anchors on a diagnosis, it is very difficult to introduce new differential diagnoses. Physician may not have considered alternate diagnoses on subsequent visits.
Patient seen in ED on day one with complaints of abdominal pain. Patient evaluated, treated, and discharged with diagnosis of UTI [urinary tract infection]. The next day, patient presented to another facility and was diagnosed with a ruptured appendix.
Premature closure. Acceptance of a diagnosis before it has been fully vetted by considering alternative diagnoses or searching for data that contradict the initial diagnosis.
Authority report stated missed diagnosis of appendicitis. Physician omitted tests that would have led to diagnosis of ruptured appendix. Physician may have failed to consider differential diagnoses during history and physical portion of examination.
Patient presented to the ED on day one with complaints of chest pain. Stress test done, results negative, and patient discharged. The next day, patient returned to the ED with chest pain and tachypnea, and the left leg was blue and mottled. Dopplers of lower extremities confirmed extensive DVT [deep-vein thrombosis].
Premature closure. Representative heuristic. Mental matching to diagnose conditions with characteristic presentations. Predisposes to lack of a differential diagnosis.
Authority report stated missed diagnosis of DVT. Physician may have anchored on diagnosis "acute coronary syndrome" due to complaints of chest pain. Physician may have latched on to representative symptom of chest pain, failing to perform tests to rule out other potential diagnoses (i.e., differential diagnoses).
A young man came to the ED for fainting and syncope, including the inability to speak for a few seconds with lateralizing symptoms and staring. In the ED, lab work was done but no CT [computed tomography] scan was ordered. Patient was discharged home with diagnosis of syncope and dehydration secondary to stress, with instructions to follow up with primary care physician. Subsequently, the primary care physician admitted the patient directly into the hospital, where a CT scan was performed and a brain lesion diagnosed.
Context errors. Occur when the diagnosing physician is biased by patient history, previous diagnosis, or other factors and the case is formulated in the wrong context.
Authority report stated missed diagnosis of brain lesion. Physician may have attributed symptoms to "stress" and evaluated patient in this context. Physician may have failed to rule out other less likely but more serious diagnoses. Physician may have formulated diagnosis in the context of a young man with admitted stress and stopped searching for other plausible diagnoses for symptoms.
- Scott IA. Errors in clinical reasoning: causes and remedial strategies. BMJ 2009 Jun 8;338:b1860.
- Groopman J. How doctors think. New York (NY): Houghton Mifflin Company; 2008.