Balla John, Heneghan Carl, Goyder Clare, Thompson Matthew
Centre for Evidence-based Medicine, University of Oxford, Oxford, UK.
BMJ Open. 2012 Sep 13;2(5). doi: 10.1136/bmjopen-2012-001539. Print 2012.
We investigate the mechanisms of diagnostic error in primary care consultations to detect warning signs for possible error. We aim to identify places in the diagnostic reasoning process associated with major risk indicators.
A qualitative study using semistructured interviews with open-ended questions.
A 2-month study in primary care conducted in Oxfordshire, UK.
We approached about 25 experienced general practitioners by email or word of mouth, 15 volunteered for the interviews and were available at a convenient time.
Interview transcripts provided 45 cases of error. Three researchers searched these independently for underlying themes in relation to our conceptual framework.
Locating steps in the diagnostic reasoning process associated with major risk of error and detecting warning signs that can alert clinicians to increased risk of error.
Initiation and closure of the cognitive process are most exposed to risk of error. Cognitive biases developed early in the process lead to errors at the end. These warning signs can be used to alert clinicians to the increased risk of diagnostic error. Ignoring red flags or critical cues was related to processes being biased through the initial frame, but equally well, it could be explained by knowledge gaps.
Cognitive biases developed at the initial framing of the problem relate to errors at the end of the process. We refer to these biases as warning signs that can alert clinicians to the increased risk of diagnostic error. We conclude that lack of knowledge is likely to be an important factor in diagnostic error. Reducing diagnostic errors in primary care should focus on early and systematic recognition of errors including near misses, and a continuing professional development environment that promotes reflection in action to highlight possible causes of process bias and of knowledge gaps.
我们研究基层医疗会诊中诊断错误的机制，以发现可能出现错误的警示信号。我们旨在确定诊断推理过程中与主要风险指标相关的环节。
一项采用开放式问题的半结构式访谈的定性研究。
在英国牛津郡进行的为期2个月的基层医疗研究。
我们通过电子邮件或口口相传联系了约25名经验丰富的全科医生，15名志愿者同意接受访谈并在方便的时间参与。
访谈记录提供了45个错误案例。三名研究人员独立在这些案例中寻找与我们概念框架相关的潜在主题。
确定诊断推理过程中与重大错误风险相关的步骤，并检测可提醒临床医生错误风险增加的警示信号。
认知过程的启动和结束最容易出现错误风险。过程早期形成的认知偏差会导致后期出现错误。这些警示信号可用于提醒临床医生诊断错误风险增加。忽视红旗标志或关键线索与过程因初始框架而产生偏差有关，但同样也可能是由于知识差距造成的。
问题初始框架阶段形成的认知偏差与过程后期的错误有关。我们将这些偏差称为警示信号，可提醒临床医生诊断错误风险增加。我们得出结论，知识缺乏可能是诊断错误的一个重要因素。减少基层医疗中的诊断错误应侧重于早期和系统地识别错误，包括险些发生的错误，以及营造一个促进在行动中反思的持续专业发展环境，以突出过程偏差和知识差距的可能原因。
