Clinical Reasoning Toolkit
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Initiatives to reduce cognitive errors focus on making practitioners meta-analytical (thinking about their thinking) during the course of clinical decision making. This "time out” can be executed as a forced habit (e.g., always ask "what other diagnosis could this be?” to avoid premature closure) or by using a diagnostic checklist. Some researchers caution that these measures will not mitigate cognitive errors and may generate additional errors or additional costs.

Quick Take: read "Cognitive Forcing Strategies in Clinical Decision Making” by Patrick Croskerry

Core resources (additional high-yield introductory information) are indicated by a STAR icon


Debiasing/Cognitive Forcing Functions/Metacognition View

Graber M et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Quality and Safety. 2012.

A comprehensive literature review of interventions that have been suggested to reduce the likelihood of cognitive errors. The authors conclude that the evidence base and research methodology need to be strengthened before many widely cited interventions can be broadly endorsed.

Croskerry P. Cognitive forcing strategies in clinical decision making. Annals of Emergency Medicine. 2003.

A broad discussion of cognitive forcing strategies including rationale for use, types of strategies (universal, generic and specific), and suggestions for implementation in clinical decision making.

Sherbino J, Yip S, Dore KL, Siu E, Normal GR. The effectiveness of cognitive forcing strategies to decrease diagnostic error: an exploratory study. Teaching and Learning in Medicine. 2011.

A study of teaching avoidance of two common biases (search satisficing and availability bias) to medical students. The intervention as assessed via low-fidelity simulation was of limited utility both immediately and at six-month follow-up.

Croskerry P. Biases and Debiasing.

A presentation outlining cognitive debiasing.

Diagnostic Checklists View

Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Academic Medicine. 2011.

A review of the potential role of diagnostic checklists in preventing diagnostic error, including the rationale for use, types of checklists (general, differential diagnosis and specific to common errors) and considerations for use.

Graber M. Checklist slides.

A comprehensive review of the potential role of checklists in diagnostic medicine including the rationale for use, the role checklists play in similar situations and several checklists clinicians may find useful.

Graber ML, Singh H, Sorenson A, et al. General Checklist for Diagnosis (AHRQ)

A suggested general diagnostic checklist for use in identifying clinical situations that pose a high risk for diagnostic error.

John Ely. Diagnostic Error M&M: Diagnostic Checklists.

A narrated slide presentation (8 minutes) of a case in which a specific diagnostic checklist was used and helped result in the correct diagnosis.

John Ely. demonstrating checklist with a patient.

A brief video demonstration of how a differential diagnosis checklist can be used collaboratively with a patient.