Why did I miss the diagnosis? Some cognitive explanations and educational implications
Why did I miss the diagnosis? Some cognitive explanations and educational implications
复制标题
DOI：
10.1097/00001888-199910000-00065
复制
发表时间：
1999-10-01
影响因子：
7.4
通讯作者：
Bordage, G
中科院分区：
文献类型：
--
作者：
Bordage, G
在过去的一年里，你为什么错过了诊断？参加继续教育活动的10位社区内科医生在过去的一年中平均报告了4次诊断错误，他们回答说（按降序排列）：我从来没有想过。我过于关注一个发现，尤其是实验室结果。我没有听够病人的故事。我太匆忙了。我对这种病了解得不够多。我让顾问说服了我。我没有重新评估形势。病人同时有太多的问题。L也受到了类似案例的影响。L没能说服病人进一步调查。我拒绝接受令人沮丧的诊断。回顾过去，这些内科医生报告的诊断错误类型代表了文献中描述的诊断错误的一个很好的横截面。有些本质上是认知的，有些是个人的，还有一些是组织的。本文的目的是描述和理解诊断错误。然而，这个领域太广了，无法解决每一种类型的错误。因此，在概述之后，我将重点关注两种错误类型：临床特征的错误检测和诊断假设的错误触发，两者都与临床遇到的初始方面有关。最后，根据所学到的经验教训，我提出了一些规划和组织临床医学导论（ICM）课程的实际意义，这些课程可以帮助学生以最佳方式收集和解释数据，从而避免检测和触发错误。
Why did you miss the diagnosis in the past year? Ten communitybased internists attending a continuing education activity, each of whom reported an average of four diagnostic errors in the past year, responded (in decreasing order): lt never crossed my mind. l paid too much attention to one finding, especially lab results. l didn't listen enough to the patient's story. I was too much in a hurry. l didn't know enough about the disease. l let the consultant convince me. l didn't reassess the situation. The patient had too many problems at once. l was influenced by a similar case. l failed to convince the patient to investigate further. I was in denial of an upsetting diagnosis.In retrospect, the types of diagnostic errors reported by these internists represent a good cross section of the diagnostic errors described in the literature. Some are cognitive in nature, others are personal, and still others are organizational. The purpose of this paper is to describe and understand diag-nostic errors. However, the field is too broad to tackle each and every type of error. Thus, after presenting an overview, l focus on two error types: faulty detection of clinical features and faulty trig-gering of diagnostic hypotheses, both related to the initial aspects of a clinical encounter. Finally, and based on the lessons learned, I present some practical implications for planning and organizing introduction to clinical medicine (ICM) courses that help students optimally gather and interpret data and thus avoid detection and triggering errors.