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Diagnosis (Berl). 2014 Jun 1;1(2):167-171. doi: 10.1515/dx-2013-0040.

Use of a novel, modified fishbone diagram to analyze diagnostic errors.

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1Associate Program Director, Internal Medicine Residency Allegheny General Hospital- West Penn Hospital Educational Consortium, Pittsburgh, PA, USA; and Assistant Professor of Medicine, Temple University School of Medicine, Philadelphia, PA, USA.
2Associate Professor of Clinical Medicine, Department of Medicine, Associate Designated Institutional Official for Quality and Safety, Graduate Medical Education, Director of Quality and Safety Education, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Penn Tower, Suite 2009, Philadelphia, PA 19104, USA.
3Vice President, Medical Affairs, Baystate Medical Center, Springfield, MA, USA; and Assistant Professor of Medicine, Tufts University School of Medicine, Boston, MA, USA.
4Assistant Professor of Medicine, Tufts University School of Medicine, Departments of Medicine and Medical Education, Maine Medical Center, Portland, ME, USA.


Diagnostic errors comprise a critical subset of medical errors and often stem from errors in individual cognition. While traditional patient safety methods for dissecting medical errors focus on faulty systems, such methods are often less useful in cases of diagnostic error, and a broader cognitive framework is needed to ensure a comprehensive analysis of these complex events. The fishbone diagram is a widely utilized patient safety tool that helps to facilitate root cause analysis discussions. This tool was expanded by the authors to reflect the contributions of both systems and individual cognitive errors to diagnostic errors. We describe how two medical centers have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets the patient safety and educational needs of their respective institutions.


cognitive error; diagnostic error; fishbone diagram; root cause analysis; systems error


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