Table 3Cognitive and affective de-biasing strategies to reduce diagnostic error

StrategyMechanism/action
Develop insight/awarenessProvide detailed descriptions and thorough characterizations of known CDRs and ADRs together with multiple clinical examples illustrating their adverse effects on decisionmaking and diagnosis formulation.
Consider alternativesEstablish forced consideration of alternative possibilities, e.g., the generation and working through of a differential diagnosis. Encourage routinely asking the question: What else might this be?
Heighten metacognitionTrain for a reflective approach to problem-solving: stepping back from the immediate problem to examine and reflect on the thinking and affective process.
Develop cognitive forcing strategiesDevelop generic and specific strategies to avoid predictable CDRs and ADRs in particular clinical situations.
Provide specific trainingIdentify specific flaws and biases in thinking and provide directed training to overcome them: e.g., instruction in fundamental rules of probability, distinguishing correlation from causation, basic Bayesian probability theory.
Provide simulation trainingDevelop mental rehearsal, “cognitive walkthrough” strategies for specific clinical scenarios to allow CDRs and ADRs to be made and their consequences to be observed. Construct new scenarios or clinical training videos contrasting incorrect (biased) approaches with the correct (debiased) approach.
Decrease reliance on memoryImprove the accuracy of judgments through cognitive aids: mnemonics, clinical practice guidelines, algorithms, hand-held computers.
Make task easierProvide more information about the specific problem to reduce task difficulty and ambiguity. Make available rapid access to concise, clear, well-organized information.
Minimize time pressuresProvide adequate time for quality decisionmaking.
Establish accountabilityEstablish clear accountability and followup for decisions made.
Improve feedbackProvide as rapid and reliable feedback as possible to decisionmakers so that errors are immediately appreciated, understood, and corrected, resulting in better calibration of decisionmakers. 23

From: Diagnostic Failure: A Cognitive and Affective Approach

Cover of Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology)
Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology).
Henriksen K, Battles JB, Marks ES, et al., editors.

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