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nicians were certain resulted wrong at autopsy
[24]. Further, even when diagnosis is right, management
errors can arise: 1 in 2 patients with
acute or chronic diseases do not receive evidencebased
therapies and 1 in 3–5 receive unnecessary
and/or potentially dangerous drugs or investigations
[19].
A third of CREs derive from deficits of execution
(slips, lapses, or oversights in carrying out
appropriate management in correctly diagnosed
patients), but almost half are errors of reasoning
or decision quality (failure to elicit, synthesize,
decide, or act on clinical information).
Death or permanent disability result in 25% of
cases, and at least three quarters of them are considered
highly preventable [22].
A cornerstone of research on CREs in IM is
the work by Graber et al. [25]. They analyzed 100
cases and grouped diagnostic errors in three
categories:
––
no-fault errors (in case of masked or unusual
disease presentation or non-collaborative
patient) 7%
––
system-related errors (technical failure and
equipment problems or organizational flaws)
19%
––
cognitive errors (faulty knowledge, data gathering,
or synthesis) 28%.
Coexisting system-related and cognitive errors
were reported in 46% of cases. Further, wrong
diagnosis was characterized by a predominance
of cognitive errors (92% vs 50%), whereas
M. L. Regina et al.
delayed diagnosis by the predominance of
system- related ones (89% vs 36%). Cases where
discrepancy resulted from autopsy were mainly
due to cognitive factors (90% vs 10%). Overall,
228 system-related factors and 320 cognitive factors,
averaging 5.9 per case, were identified [26].
Among cognitive factors, faulty data gathering
(14%) or synthesis (83%) resulted more frequently
involved than faulty knowledge (3%)
[26].
Clinical reasoning can proceed analytically or
non-analytically (Table 17.4) to generate diagnostic
hypotheses, investigations, and treatment.
Analytical reasoning (also called “hypotheticdeductive
model”) is commonly used by younger
physicians or in unfamiliar or unusual cases and
is based on lists of differential diagnoses and
gathering of information to validate such
diagnoses. Non-analytical reasoning is faster and
based on mental heuristics (maxims, shortcuts,
rules of thumb) or pattern recognition. In practice,
physician compare current patient’s symptoms/signs
with previous cases, collected through
clinical experience and/or study and get the right
diagnosis in few seconds [27]. One type does not
exclude the other and they can be mutually used
in the same patient. None of them is error-proof.
If mental heuristics and pattern recognition are
efficient and accurate in many situations, they
can also predispose to errors, as patient’s picture
does not always fit the expected pattern, because
of an atypical presentation, comorbidities, or
Table 17.4 Types of clinical reasoning: a comparison [27]
Non-analytical (system 1) Characteristics Analytical (system 2)
Intuitive (based on pattern Modality
Hypothetic- deductive
recognition and heuristic)
Developed through clinical
experience and study
Development
Generation of list of diagnoses to
be validated
Commonly used by expert/senior
physicians
Application
Commonly used by not expert/
younger physicians
Commonly used in atypical or
unfamilial cases
Minor cognitive load
Automatic, unconscious
Awareness
Major cognitive load
Conscious
Faster
Diagnosis in 10 s
Time
Slower
Diagnosis in minutes/hours
More efficient Efficiency Less efficient (based on memory
work)