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Qual Saf Health Care. 2006 Jun;15(3):159-64.

Understanding diagnostic errors in medicine: a lesson from aviation.

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Division of Health Policy and Quality, Houston Center for Quality of Care and Utilization Studies, Michael E DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.


The impact of diagnostic errors on patient safety in medicine is increasingly being recognized. Despite the current progress in patient safety research, the understanding of such errors and how to prevent them is inadequate. Preliminary research suggests that diagnostic errors have both cognitive and systems origins. Situational awareness is a model that is primarily used in aviation human factors research that can encompass both the cognitive and the systems roots of such errors. This conceptual model offers a unique perspective in the study of diagnostic errors. The applicability of this model is illustrated by the analysis of a patient whose diagnosis of spinal cord compression was substantially delayed. We suggest how the application of this framework could lead to potential areas of intervention and outline some areas of future research. It is possible that the use of such a model in medicine could help reduce errors in diagnosis and lead to significant improvements in patient care. Further research is needed, including the measurement of situational awareness and correlation with health outcomes.

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