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  • General

    Improving Clinical Reasoning, Reducing Diagnostic Errors

     

     

    Instructor:

    Prof. Dr. Chew Keng Sheng, MD, MMed

    Course Synopsis

    Welcome to Improving Clinical Reasoning, Reducing Diagnostic Errors! The course introduces the learners to the overarching concepts in patient safety with a particular focus on the importance of good clinical reasoning, the impact of cognitive errors as a source of diagnostic errors as well as some strategies in minimizing them. How a clinician thinks influences how he or she makes clinical decisions, in particular, in terms of differential diagnoses generation and consideration as well as therapeutic options. The course also introduces the learner to the dual process theory of thinking as a predominant framework on our thought process as well as the limitations and fallacies of this model. This course is not only about delivering unique contents  but also curating some of the best yet free resources for the learners to explore and learn further.

    By the end of this course, the learners will be able to:
    • describe sources that may compromise patient safety
    • describe the impact of diagnostic errors on patient safety
    • describe the dual process theory of thinking as a conceptual model for clinical reasoning as well as the limitations of this model
    • state the classes of cognitive errors and give examples of each
    • describe the affective errors impacting the quality of clinical decisions
    • state and apply strategies to minimize cognitive errors in clinical decisions
    • apply a mnemonic checklist called the TWED checklist to minimize cognitive errors in clinical decision making

    Creative Commons LicenseThis OpenCourseWare@UNIMAS and its related materials are licensed under aCreative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

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  • Lesson 1 Introduction To Patient Safety

    In this lesson, the learner will learn about the sources of errors that may compromise patient safety in the hospital, particularly in the context of emergency department as well as the the impact of diagnostic errors on patient safety. The learners will also learn about the influence of the clinician’s thought processes on patient safety.

    By the end of this lesson, the learners will be able to

    1. describe the conceptual framework of patient safety and patient safety culture
    2. describe the sources of errors that can affect patient safety
    3. be aware of the tendency for blame culture when things go wrong
    4. explain the Swiss-cheese model for the manifestation of active errors
    5. recognize the fallibility of human beings

  • Lesson 2 Dual Process Theory of Thinking

    • In this lesson, the learners will learn about the importance of our cognitive processes in influencing our clinical decisions. Specifically, the dual process theory of thinking as a conceptual model for reasoning will be explained in details.  Models of clinical reasoning will then be described. Nonetheless, the dual process theory of thinking is not without its limitations and potential misconceptions. One of these misconceptions will be described. Despite its limitations and potential misconceptions, dual process theory of thinking is still a useful model to describe clinical reasoning.

      By the end of this lesson, the learners will be able to

      1. Explain the concept of dual process theory of thinking
      2. Identify the interplay of Type 1 and Type 2 cognitive processes in clinical setting as well as everyday life
      3. Describe clinical reasoning and two models of clinical reasoning
      4. Describe the limitations and misconception of the dual process theory of thinking

    • Activity 1
      The concept of dual process theory of thinking is well described in the book by Daniel Kahnemann, Thinking, Fast and Slow. Watch this video on the summary of this book, explaining the dual process theory and many more contents from the book.

    • Activity 2 (Fun Activity)

    • Activity 3 (MAIN PRESENTATION): Dual Process Theory of Thinking

    • Activity 4 Meet the Expert's Lecture

  • Lesson 3 Cognitive Errors (Part 1)

    In this lesson, the learners will learn about the classes of cognitive errors or cognitive biases. Cognitive errors or biases refer to our predisposition to react in a way that deviates from our rationality. In particular, the last 3 classes in the classification of cognitive errors by Campbell et al (2007), which is adapted in this module, refers to the emotional and environmental influences that increase our predisposition to commit cognitive errors.

    By the end of this lesson, the learners will be able to

    1. list the classes of cognitive errors 
    2. describe and give examples of cognitive errors in each of these classes of cognitive errors

  • Lesson 4 Cognitive Errors (Part 2)

    In this lesson, a summary on the important cognitive errors learned in the previous lesson will first be presented. The learners will then learn about the affective factors that may increase the risk or vulnerability of clinicians in committing cognitive errors. In particular, the learners will learn about the four types of patients that many clinicians dread to see, and thus, increases their propensity to cognitive errors when managing these types of patients. The learners will also learn about the importance of maintaining the day-sleep cycle and the effects of sleep deprivation. And finally, a discussion on the challenges in implementing strategies to minimize cognitive errors will be outlined.

    By the end of this lecture, the learners will be able to
    1. describe the influence of affective (emotional) and environmental factors on increasing the risk of committing cognitive errors
    2. describe the challenges in implementing strategies to minimize cognitive errors

    • Activity 1 (Fun song on cognitive biases)

      Who says learning cognitive biases or errors have to be in a serious manner? Come on in to our "studio" page, to listen and sing along this catchy tune on cognitive biases.

    • Activity 2: Meet the Expert's Lecture

    • Activity 3 (MAIN PRESENTATION): Cognitive Errors Part 2

    • Activity 4 Podcast on cognitive biases from IMReasoning.com

    • Reading Material:

      In this short article by Campbell et al, they classify cognitive errors into 7 categories. Their classification is adapted and used in this course as well. Citation: Campbell SG, Croskerry P, Bond WF. Profiles in patient safety: A "perfect storm" in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2007;14(8):743-9.

  • Lesson 5 Strategies to Minimize Cognitive Errors

    • In this final lesson, the different strategies of minimizing cognitive errors will be outlined. The learners will be directed to read further on these strategies in the recommended reading materials. The challenges in implementing strategies to minimize cognitive errors as well as the importance of metacognition will be delineated. The learners will also be introduced to the concept of cognitive load and the need to take the various cognitive loads into account when designing strategies to minimize cognitive errors.

      At the end of this lecture, the learners will be able to

      1. outline the strategies in minimizing cognitive errors
      2. outline the high risk situations that increase our risk of committing cognitive errors
      3. describe metacognition and its importance in monitoring our thinking process
      4. describe the importance of taking the impact of cognitive loads into account in designing strategies to minimize cognitive errors

    • Activity 1

    • Activity 2 Meet the Expert's Lecture

    • Activity 3 (MAIN PRESENTATION) Strategies to minimize cognitive errors

    • Reading materials

    • Article 1:

      Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual Saf 2013 Oct;22 Suppl 2:ii58-ii64.

    • Article 2:
      Croskerry P, Singhal G, Mamede S. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf 2013 Oct;22 Suppl 2:ii65-ii72.

    • Recommended external resources for learners to explore further

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