Fatal flaws in clinical decision making.

Area of Science:

• Medical error analysis
• Surgical quality improvement
• Patient safety research

Background:

• Clinical decision making is fundamental to surgical practice, involving continuous data interpretation.
• Patient deaths linked to clinical incidents highlight failures in decision-making processes.
• Understanding these failures is crucial for learning and improving surgical care.

Purpose of the Study:

• Identify patient deaths resulting from inadequate clinical decision making.
• Determine the specific stage of the decision-making process where failures occurred.
• Extract lessons for the surgical community from analyzed incidents.

Main Methods:

• Analysis of the Australian and New Zealand Audit of Surgical Mortality database (2015).
• Identification of deaths with inadequate patient management.
• Individual review of clinical incidents to classify clinical decision-making incidents (CDMIs).

Main Results:

• 226 CDMIs identified from 3422 audited deaths.
• Decision to operate was the most common CDMI (43.8%).
• Diagnostic error (21.7%) and inadequate post-operative assessment (6.2%) were also identified.

Conclusions:

• Clinical decision-making failures, particularly the decision to operate, are implicated in patient deaths.
• Further evaluation of CDMIs is recommended to enhance surgical mortality assessment.
• Learning from these incidents can improve surgical practice and patient outcomes.