{"product_id":"cognitive-autopsy-a-root-cause-analysis-of-medical-decision-making-9780190088743","title":"Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making","description":"Behind heart disease and cancer, medical error is now listed as one of the leading causes of death. Of the many medical errors that may lead to injury and death, diagnostic failure is regarded as the most significant. Generally, the majority of diagnostic failures are attributed to the clinicians directly involved with the patient, and to a lesser extent, the system in which they work. In turn, the majority of errors made by clinicians are due to decision making failures manifested by various departures from rationality. Of all the medical environments in which patients are seen and diagnosed, the emergency department is the most challenging. It has been described as a \"wicked\" environment where illness and disease may range from minor ailments and complaints to severe, life-threatening disorders. \u003cp\u003e\u003c\/p\u003e\u003cem\u003eThe Cognitive Autopsy\u003c\/em\u003e is a novel strategy towards understanding medical error and diagnostic failure in 42 clinical cases with which the author was directly involved or became aware of at the time. Essentially, it describes a cognitive approach towards root cause analysis of medical adverse events or near misses. Whereas root cause analysis typically focuses on the observable and measurable aspects of adverse events, the cognitive autopsy attempts to identify covert cognitive processes that may have contributed to outcomes. In this clinical setting, no cognitive process is directly observable but must be inferred from the behavior of the individual clinician. The book illustrates unequivocally that chief among these cognitive processes are cognitive biases and other flaws in decision making, rather than knowledge deficits.\u003cbr\u003e\u003cbr\u003e\u003cbr\u003e\u003cbr\u003e\u003cb\u003eAbout the Author\u003c\/b\u003e\u003cbr\u003ePat Croskerry, MD, PhD, is Professor of Emergency Medicine and in the Division of Medical Education \u0026amp; Continuing Professional Development, Faculty of Medicine at Dalhousie University in Halifax, Nova Scotia, Canada. In addition to his medical training, he holds a doctorate in Experimental Psychology and a Fellowship in Clinical Psychology. He has published over 90 journal articles and 40 book chapters in the area of patient safety, clinical decision making and medical education reform. Two of his papers are in the top 5 cited papers in the emergency medicine education literature. In 2006, he was appointed to the Board of the Canadian Patient Safety Institute, and in the same year received the Ruedy award from the Association of Faculties of Medicine of Canada for innovation in medical education. He has given over 500 keynote presentations at leading medical schools, hospitals, and universities around the world. \u003cem\u003eForeword\u003cbr\u003ePreface\u003cbr\u003eAcknowledgements\u003c\/em\u003e \u003cp\u003e\u003c\/p\u003eIntroduction \u003cp\u003e\u003c\/p\u003e\u003cstrong\u003eThe Cases\u003c\/strong\u003e\u003cbr\u003eCase 1. Christmas Surprises\u003cbr\u003eCase 2. Distraught Distraction\u003cbr\u003eCase 3. The Fortunate Footballer\u003cbr\u003eCase 4. An Incommoded Interior Designer\u003cbr\u003eCase 5. Teenage Tachypnoea\u003cbr\u003eCase 6. The Backed-up Bed Blocker\u003cbr\u003eCase 7. The English Patient\u003cbr\u003eCase 8. Lazarus Redux\u003cbr\u003eCase 9. A Model Pilot\u003cbr\u003eCase 10. A Rash Diagnosis\u003cbr\u003eCase 11. The Perfect Storm\u003cbr\u003eCase 12. A Case of Premature Closure\u003cbr\u003eCase 13. Postpartum Puzzler\u003cbr\u003eCase 14. The Blind Leading the Blindable\u003cbr\u003eCase 15. Pseudodiagnosis of Pseudoseizure\u003cbr\u003eCase 16. Failed Frequent Flyers (a and b)\u003cbr\u003eCase 17. Explosions, Expletives and Erroneous Explanations\u003cbr\u003eCase 18. The Representativeness Representative\u003cbr\u003eCase 19. The Michelin Lady\u003cbr\u003eCase 20. An Instable Inadvertence\u003cbr\u003eCase 21. A Laconic Lad\u003cbr\u003eCase 22. The Misunderstood Matelot\u003cbr\u003eCase 23. A Hard Tale to Swallow\u003cbr\u003eCase 24. A Rake's Progress\u003cbr\u003eCase 25. Deceptive Detachment\u003cbr\u003eCase 26. A Search Satisfied Skateboarder\u003cbr\u003eCase 27. The Vacillated Vagrant\u003cbr\u003eCase 28. A Tale of Two Cycles (a and b)\u003cbr\u003eCase 29. Misleading Mydriasis\u003cbr\u003eCase 30. Bungled Bullae\u003cbr\u003eCase 31. Overdosing the Overdosed\u003cbr\u003eCase 32. The Lost Guide\u003cbr\u003eCase 33. Hazardous Handover\u003cbr\u003eCase 34. Double Trouble\u003cbr\u003eCase 35. Tracking Fast and Slow\u003cbr\u003eCase 36. Alternate Alternatives\u003cbr\u003eCase 37. Notable Near-miss\u003cbr\u003eCase 38. A Stone Left Unturned\u003cbr\u003eCase 39. Sweet Nothings\u003cbr\u003eCase 40. Straining the Strain Diagnosis\u003cbr\u003eCase 41. Missed It\u003cbr\u003eConclusion: Strategies for Improving Clinical Decision Making \u003cp\u003e\u003c\/p\u003e\u003cem\u003eAppendix A: Diagnoses in 42 Cases\u003cbr\u003eAppendix B: Probable Biases and Their Frequencies in 42 Clinical Cases\u003cbr\u003eAppendix C: Analysis of Ordinal Position of Bias in Clinical Cases\u003cbr\u003eAppendix D: Potential Error-Producing Conditions\u003cbr\u003eAppendix E: Analysis of Knowledge-Based Errors in the Case Series\u003cbr\u003eGlossary of Biases and Their Cognitive Factors\u003cbr\u003eIndex\u003c\/em\u003e\u003cbr\u003e","brand":"Oxford Univ PR","offers":[{"title":"Default Title","offer_id":50874469908754,"sku":"9780190088743","price":88.99,"currency_code":"USD","in_stock":true}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/0831\/4771\/8930\/files\/img_d7d3e790-377d-4b40-9cc6-ea52302e815a.jpg?v=1737994712","url":"https:\/\/surprise-castle.myshopify.com\/products\/cognitive-autopsy-a-root-cause-analysis-of-medical-decision-making-9780190088743","provider":"Surprise Castle","version":"1.0","type":"link"}