“Behind heart disease and cancer, medical error is now listed as one of the leading causes of death.”
That’s an attention-getter, isn’t it? This line opens the back cover introduction to the just-released, “The Cognitive Autopsy,” by Professor of Emergency Medicine at Dalhousie University and doctor two times over (MD, PhD), Pat Crosskerry.
“Of the many medical errors that may lead to injury and death, diagnostic failure is regarded as the most significant. Generally, the majority of diagnostic failures are attributed to the clinicians directly involved with the patient, and to a lesser extent, the system in which they work. In turn, the majority of errors made by clinicians are due to decision making failures manifested by various departures from rationality. Of all the medical environments in which patients are seen and diagnosed, the emergency department is the most challenging. It has been described as a “wicked” environment where illness and disease may range from minor ailments and complaints to severe, life-threatening disorders.”
Dr. Crosskerry , widely published in journals and books on the subjects of patient safety and clinical decision making, award winner in medical education, YouTube resource, and founder of the Canadian Symposium on Patient Safety, has gathered together 42 actual emergency room cases resulting in, “…medical adverse events or near misses.” and examines the thought processes that may have contributed to those less than ideal outcomes. Tellingly, cognitive biases are larger factors than a lack of relevant knowledge in these errors, and by clearly laying out the forces behind these errors, this book helps readers move towards avoiding and eliminating them.
(And while the cases examined here all took place in the ‘wicked environment’ of the emergency room -with all the extra pressures that may make a practitioner more vulnerable to these errors- readers in any branch of medicine could benefit from the lessons taught here.)
“Where did I go wrong?” can be a valuable question, but not if it’s an idle one. Finding the answer to that question can change -even save- lives.
“The Cognitive Autopsy” can be purchased for mail out or pick up from the Dalhousie Bookstore here, (we’re also open to walk-in traffic from 11-3 on weekdays until December 23rd), or through our online affiliate, Login Canada (free shipping on orders placed in 2020), here.