Cognitive error in an academic emergency department

Benjamin H. Schnapp, Jean E. Sun, Jeremy L. Kim, Reuben J. Strayer, Kaushal H. Shah

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Medical error is a leading cause of death nationwide. While systems issues have been closely investigated as a contributor to error, little is known about the cognitive factors that contribute to diagnostic error in an emergency department (ED) environment. Eight months of patient revisits within 72 h where patients were admitted on their second visit were examined. Fifty-two cases of confirmed error were identified and classified using a modified version of the Australian Patient Safety Foundation classification system for medical errors by a group of trained physicians. Faulty information processing was the most frequently identified category of error (45% of cases), followed by faulty verification (31%). Faulty knowledge (6%) and faulty information gathering (18%) occurred relatively infrequently. "Misjudging the salience of a finding" and "premature closure" were the individual errors that occurred most frequently (13%). Despite the complex nature of diagnostic reasoning, cognitive errors of information processing appear to occur at higher rates than other errors, and in a similar pattern to an internal medicine service despite a different clinical environment. Further research is needed to elucidate why these errors occur and how to mitigate them.

Original languageEnglish
Pages (from-to)135-142
Number of pages8
Issue number3
StatePublished - 25 Sep 2018
Externally publishedYes


  • classification
  • cognitive
  • diagnosis
  • diagnostic error
  • emergency
  • error
  • information processing


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