Table 4Cognitive and affective autopsy

  • Conduct as soon as possible after event
  • Avoid discussion with others
  • Be well-rested and have an adequate amount of sleep
  • Find a secluded place, free of interruptions
  • Start with the beginning of the day or shift and work through towards the event
  • Free-associate fully about the event—recall thoughts and feelings
  • Pay close attention to ambient conditions
  • Write down everything, however trivial
  • Discuss with others and record their comments and observations
  • Review the CDRs and ADRs
  • Identify which were involved and their respective impacts

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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