A Proposed Systematic Approach to the Cognitive Autopsy for Internists.

The cognitive autopsy has been a proposed tool for physicians to evaluate misdiagnosis. However, prior iterations of this tool are cumbersome, not designed for the internist, and may cause users to isolate cognition from systems issues. A 10-point tool was created to be utilized individually or by a group when evaluating an adverse event. This could be used with Croskerry's 2020 "cognitive autopsy" or as a standalone tool for internists. We trialed this tool in large group formats and with individual residents; all reported an improved appreciation of the factors leading to poor outcomes and medical errors.