2021_Book_TextbookOfPatientSafetyAndClin

17 Patient Safety in Internal Medicine
evolving diseases [28]. Another Achille’s heel of
non-analytical reasoning (N-AR) are biases,
constructs founded on perceptions, prejudices or
ideologies, outside of critical thinking. Bias can
be distinguished in internal or external to the clinicians
[19] either in cognitive or affective bias
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[27] (see Table 17.5). Breakdowns in analytical
reasoning most often derive from not following
appropriate diagnostic “rules” and include: missing
key data, inadequate review of existing data,
deficits in medical knowledge, lacking skills in
evidence-based practice and decision-making,
Table 17.5 Bias and heuristics in clinical reasoning: examples and corrective strategies [19]
Bias Description Example Corrective strategy
Anchoring
Tendency to fixate on first
impression and not to
consider further
information available
Availability
Confirmation
Diagnosis
momentum bias
Framing a
Gambler’s fallacy
Tendency to accept the
diagnosis that more easily
comes to mind because of
recent observation rather
than to consider
prevalence and incidence
of such diagnosis
To look only for signs and
symptoms that confirm
your favorite hypothesis
or to interpret clinical
findings only to support
such hypothesis, without
looking for or even
disregarding opposite
evidences
To consider definite a
diagnosis without
evidence, but due to a
label applied to the first
contact and transmitted by
all the people who took
care of the patient
To decide on options
based on whether the
options are presented with
positive or negative
connotations or to be
influenced by the context
To believe a diagnosis less
probable, if it occurred in
several previous patients
The physician diagnosed a viral
meningitis instead of cervical
osteomyelitis on the basis of high
fever and neck pain, ignoring
neck pain worsened not only on
flexion, but also on palpation and
previous fore-harm wound
The physician diagnosed a viral
meningitis instead of cervical
osteomyelitis, as he had just seen
a case of viral meningitis
The physician diagnosed a skin
rash under the axilla of a diabetic
patient as intertrigo missing a
diagnose of erythema migrans
due to Lyme disease
The physician attributed to
alcohol withdrawal syndrome the
psychomotor agitation of a patient
with a sticky label of alcoholic,
missing a life-threatening sepsis
The physician may decide to
request a cranial CT scan in the
same patient more often if it has
been presented as associated with
90% of true positives than 10% of
false negatives
The physician may diagnose more
easily a ruptured abdominal
aneurysm in ER than in outpatient
clinic
The physician missed a diagnosis
of pulmonary embolism as he
diagnosed four cases of
pulmonary embolism in the last
week
Think beyond your
favorite diagnosis or first
impression
Reconsider initial
diagnosis when new data
or unexpected clinical
course
Consider always disease
prevalence and incidence
Utilize an objective tool,
such as a differential
diagnosis checklist, to
verify if diagnosis
correlates with technical
findings
Critically review
diagnoses of others and
look for evidence to
support them
Change perspective
Consider always pre-test
probability
(continued)