Checklist of cognitive contributions to diagnostic errors: A tool for clinician-educators

Abstract

Background. Experienced clinician-educators readily identify trainees making diagnostic errors, but lack pedagogic expertise to make educational diagnoses and provide feedback. Simple tools are needed to address this challenge. Objectives. To characterise cognitive contributions to diagnostic errors (CCDEs) that trainees make in patient encounters and examiners’ perceptions of a checklist to document and provide feedback on these errors. Methods. Thirty examiners used a 17-item checklist to document CCDEs made by medical residents failing patient encounters in a national specialist examination. A survey was used to explore examiners’ perceptions of the checklist to document and provide feedback on these errors. Results. There were 98/264 failed patient encounters (37%). Ninety-four completed checklists documented 691 CCDEs (median of 7 per encounter). Data synthesis was more problematic than data gathering, faulty knowledge or data interpretation ( p <0.001 for all comparisons). The ‘top 5’ individual CCDEs were failure to elicit history and/or examination findings; poor knowledge of clinical features (illness scripts); case synthesis (‘putting the case together’); and misinterpretation of clinical findings. Examination-related errors were more common than history-related errors ( p <0.0001). Examiners found the checklist comprehensive and easy to use. They thought it could improve feedback on CCDEs to unsuccessful candidates and guide remediation and training at the bedside. Conclusions. A 17-item checklist identified three priority CCDEs requiring remediation and training in medical residency programmes: improving clinical skills; developing adequate illness scripts; and putting a case together. Examiners endorsed the use of the checklist and its potential to improve feedback and training, addressing CCDEs made by trainees.