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Cited by 27Clinical Reasoning and Diagnostic SkillsPatient Safety and Medication ErrorsElectronic Health Records Systems

Mind the Overlap: How System Problems Contribute to Cognitive Failure and Diagnostic Errors

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Gupta, Ashwin, Harrod, Molly, Quinn, Martha, Manojlovich, Milisa, Fowler, Karen E., Singh, Hardeep, Saint, Sanjay, Chopra, Vineet·2018·Diagnosis
DOI 10.1515/dx-2018-0014PMC PMC6743477
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Abstract

Background: Traditionally, research has examined systems- and cognitive-based sources of diagnostic error as individual entities. However, half of all errors have origins in both domains. Methods: We conducted a focused ethnography of inpatient physicians at two academic institutions to understand how systems-based problems contribute to cognitive errors in diagnosis. Medicine teams were observed on rounds and during post-round work after which interviews were conducted. Field notes related to the diagnostic process and the work system were recorded, and findings were organized into themes. Using deductive content analysis, themes were categorized based on a published taxonomy to link systems-based contributions and cognitive errors such as faulty data gathering, information processing, data verification and errors associated with multiple domains. Results: Observations, focus groups and interviews of 10 teams were conducted between January 2016 and April 2017. The following themes were identified: (1) challenges with interdisciplinary communication and communication within the electronic medical record (EMR) contributed to faulty data gathering; (2) organizational structures such as the operation of consulting services in silos promoted faulty information processing; (3) care handoffs led to faulty data verification and (4) interruptions, time constraints and a cluttered physical environment negatively influenced multiple cognitive domains. Conclusions: Systems-based factors often facilitate and promote cognitive problems in diagnosis. Linking systems-based contributions to downstream cognitive impacts and intervening on both in tandem may help prevent diagnostic errors.

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  • Excessive clerical tasks interrupt clinicians' critical thinking about diagnostic evaluation and compress patient interaction.

    “The excessive clerical tasks not only interrupt clinicians’ critical thinking about diagnostic evaluation [115] but also compress patient interaction.”

    From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [115]

  • Sharing the same room in a cluttered and noisy space can disrupt medical and nursing staff thinking and reasoning for diagnostic results.

    “Additionally, since medical and nursing staff often need to share the same room, the cluttered and noisy space can easily disrupt their thinking and reasoning for diagnostic results [115].”

    From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [115]

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Authors
Gupta, A., Harrod, M., Quinn, M., Manojlovich, M., Fowler, K. E., Singh, H., Saint, S., & Chopra, V.
Affiliations
  • University of Michigan (US)
  • VA Ann Arbor Healthcare System (US)
  • Michael E. DeBakey VA Medical Center (US)
Corresponding author
Gupta, Ashwin
ORCID
Venue
Diagnosis
Publisher
Walter de Gruyter GmbH
Published
2018-07-14
Volume
5
Issue
3
Pages
151-156
ISSN
  • 2194-8011 (ISSN-L)
  • 2194-802X
DOI
10.1515/dx-2018-0014
PMC
PMC6743477
OpenAlex
W2883999715
Cited by
27
References
29
Citations by year
2026: 2 · 2024: 3 · 2023: 4 · 2022: 2 · 2021: 3 · 2020: 7 · 2019: 4 · 2018: 2
FWCI
4.58
Type
journal article
Language
en
Open access
Locations
  • Diagnosis (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • Griffith Research Online (submittedVersion)
Funders
Agency for Healthcare Research and Quality (P30HS024385)
Topics
  • Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
  • Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
Keywords
diagnostic errors, cognitive failure, interdisciplinary communication, electronic health records, information processing, data verification, interruptions, time constraints, consulting services, diagnostic process
MeSH terms
Clinical Decision-Making, Anthropology, Cultural, Cognition, Data Collection, Diagnostic Errors, Hospital Communication Systems, Humans, Inpatients, Physicians, Focus Groups, Medical Errors, Observation

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