Diagnostic error - cause or outcome, event or process

Karen Cosby kcosby40 at GMAIL.COM
Tue Apr 11 18:53:09 UTC 2017


While thinking about this I stumbled across a powerpoint I found online
several years ago that still resonates with insight on this topic
(attached).  I would suggest that most of us are heavily influenced by
outcome and have a tough time separating outcome from our judgment about
error.  Frankly I know that the single most impactful factor in assessing
an error to me is regret.  Having arrived at an outcome, do I regret what
happened?  If I find myself thinking that surely something different might
have made a difference to improve outcome, inevitably I conclude that it
should have happened. Even if I could overcome this bias to be more
objective, others won't try to (why should they?).  That is simply the
nature of human judgment about events.

On Tue, Apr 11, 2017 at 7:33 AM, Elias Peter <pheski69 at gmail.com> wrote:

> Bob Latino wrote an interesting blog post about error here:
>
> https://www.linkedin.com/pulse/error-cause-outcome-bob-latino?published=t
>
> (Disclaimer - he included a comment I provided as feedback when I read it.)
>
> I think it is very pertinent to the discussions this group has about the
> nature of diagnostic error, and I’d be interested in hearing what the group
> thinks. I’ll hold off on contributing my thoughts to avoid framing the
> conversation.
>
>
> Peter Elias, MD
>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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