Understanding Diagnostic Errors in Medicine

A Lesson from Aviation

The authors present a real-life case in which a patient's spinal cord compression was delayed to illustrate how "situational awareness" (SA) can be used to understand diagnostic errors in medicine. SA is defined as "a person's perception of the elements in the environment within a defined space and time," including anticipating events in the near future. SA is a critical concept in fields such as aviation and spans both cognitive and systems-based error analysis. This paper discusses three tiered levels of SA: perception of information; comprehension and information processing; and forecasting of future events.

The authors analyze the patient's medical history using the language of SA methodology, in particular to understand why the misdiagnosis continued as the case progressed. The patient was being treated for prostate cancer, and his progressive neurological symptoms were misdiagnosed as cervical radiculopathy; none of his physicians considered the possibility of spinal cord compression due to a metastatic tumor. The authors point out how each member of the medical team failed to integrate new information correctly, and thus failed to achieve SA. Instead, each physician proceeded as if the assumptions of other team members were correct.

Currently, there is no "comprehensive theory of medical diagnostic problem solving that addresses both the system and cognitive origin of diagnostic errors." Thus, the authors hope that an analysis such as this can be a useful tool in filling this gap.