Investigating cognitive factors and diagnostic error in a presentation of complicated multisystem disease

Objectives: To use a case review approach for investigating the types of cognitive error identifiable following a complicated patient admission with a multisystem disorder in an acute care setting where diagnosis was difficult and delayed. Methods: A case notes review was undertaken to explore the cognitive factors associated with diagnostic error in the case of an 18-year-old male presenting acutely unwell with myalgia, anorexia and vomiting. Each clinical interaction was analysed and identified cognitive factors were categorised using a framework developed by Graber et al. Results: Cognitive factors resulting in diagnostic errors most frequently occurred within the first five days of hospital admission. The most common were premature closure; failure to order or follow up an appropriate test; over-reliance on someone else's findings or opinion; over-estimating or underestimating usefulness or salience of a finding, and; ineffective, incomplete or faulty history and physical examination. Cognitive factors were particularly frequent around transitions of care and patient transfers from one clinical area to another. The presence of senior staff did not necessarily mitigate against diagnostic error from cognitive factors demonstrated by junior staff or diagnostic errors made out-of-hours. Conclusions: Cognitive factors are a significant cause of diagnostic error within the first five days after admission, especially around transitions of care between different clinical settings and providers. Medical education interventions need to ensure clinical reasoning training supports individuals and teams to develop effective strategies for mitigating cognitive factors when faced with uncertainty over complex patients presenting with non-specific symptoms in order to reduce diagnostic error