Use of a Modified Fishbone Diagram to Analyze Diagnostic Errors in Emergency Physicians

Reilly et al. described a structured approach to the analysis of diagnostic errors by using a novel modifi ed fi shbone diagram. The application of this tool in emergency medicine had not previously been reported. The objective of this study is to use the modified fishbone diagram analysis method in examining the causes of common diagnostic errors committed by emergency physicians and the circumstances associating errors in cognitive processes.

Sixty-one cases of diagnostic errors involving ten board-certified emergency physicians (EPs) were identifi ed through a peer review process. Using a qualitative study approach, in-depth semi structured interviews with EPs was conducted. All interview audiotapes were transcribed verbatim. Content analysis was performed on all textual data to identify the factors underlying errors using the modified fishbone diagram.

In 61 cases, 165 diagnostic errors were identified (2.7 per case). The underlying contributions to errors fell into 7 categories: cognitive process (54/61, 89%), specific presentation (32/61, 52%), clinical data gathering (24/61, 39%), organization issues (12/61, 20%), affective factors (9/61, 15%), context of care (9/61, 15%), and communication (5/61, 8%). Of these cognitive errors were the most common. However, only six cases occurred in isolation (6/54, 11%), with the remaining 48 cases (48/54, 89%) occurring with other types of errors, the most common being specific presentation (28/54, 52%) and clinical data gathering (24/54, 44%).

The modified fishbone diagram is a useful tool to identify various categories of errors on diagnostic process in emergency department (ED). These fi ndings provide a basis on which to build a framework for teaching EPs how to avoid misdiagnoses in the ED setting.