176 How Common are Cognitive Errors in Cases Presented at Emergency Medicine Resident Morbidity and Mortality Conference?

Abstract

Cognitive errors are increasingly recognized as a major contributor to medical error. Traditionally, medical errors at teaching hospitals are analyzed in morbidity and mortality (M&M) conference. We aim to describe the frequency of cognitive errors relative to other error types, in cases presented at an emergency medicine resident M&M conference. We conducted a retrospective study of all cases presented at the Beaumont Emergency Medicine residency monthly M&M conference from September 2011 to August 2016. Each case was reviewed using the electronic medical record and peer review committee notes by two emergency physicians. Each case was categorized by type of primary medical error that occurred as described by Okafor et al. When a diagnostic error occurred, the case was reviewed for cognitive and non-cognitive factors that contributed. Finally, when a cognitive error occurred, the case was reviewed and classified into faulty knowledge, faulty data gathering, or faulty synthesis, as described by Graber et al. Disagreements in error type were mediated by a third emergency physician. 87 M&M cases were reviewed; the two reviewers were in agreement on 73 cases, and 14 cases required mediation by a third reviewer. No medical error was identified in 22 cases. 48 cases involved diagnostic errors, 2 cases involved procedural errors, 5 cases involved inappropriate disposition errors, 6 cases involved inappropriate or delayed therapy errors, 1 case was due to inappropriate or delayed testing error, and 3 cases due to other. Of the 48 cases with primary diagnostic error, 47 were due to cognitive errors. Of these 47 cases, 39 cases were due to faulty synthesis, 22 cases were due to faulty data gathering, and 11 cases were due to faulty knowledge. 20 cases contained more than one type of cognitive error. Resident emergency physicians are presented with an important opportunity to learn from errors at M&M conferences. Although a core competency of residency training is mastering a fundamental body of knowledge, our review of 87 M&M cases shows that diagnostic errors are less likely due to deficient knowledge, and more likely due to cognitive errors. In order to reduce future medical errors and improve patient care, residency training should include education on identification of cognitive errors and how to avoid them.