Document Detail

Zebra in the intensive care unit: a metacognitive reflection on misdiagnosis.
MedLine Citation:
PMID:  22963217     Owner:  NLM     Status:  MEDLINE    
Misdiagnosis of the cause of illness in critically ill patients is common, and a major cause of morbidity and mortality. We reflect upon a misdiagnosis that occurred in the intensive care unit of a metropolitan teaching hospital, and highlight the susceptibility of medical decision making to error. We examine recent advances in cognitive theory and how these apply to diagnosis. We discuss the vulnerability of such processes and - with particular reference to our case - why even knowledgeable and diligent clinicians are prone to misdiagnose. Finally, we review potential solutions, both educational and systemic, that may guard against the inevitable failings of the human mind, especially in a busy modern intensive care setting.
Stuart A Gillon; Sam T Radford
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Publication Detail:
Type:  Case Reports; Journal Article    
Journal Detail:
Title:  Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine     Volume:  14     ISSN:  1441-2772     ISO Abbreviation:  Crit Care Resusc     Publication Date:  2012 Sep 
Date Detail:
Created Date:  2012-09-11     Completed Date:  2012-11-01     Revised Date:  2013-05-08    
Medline Journal Info:
Nlm Unique ID:  100888170     Medline TA:  Crit Care Resusc     Country:  Australia    
Other Details:
Languages:  eng     Pagination:  216-20     Citation Subset:  IM    
Department of Intensive Care, Austin Health, Melbourne, VIC, Australia.
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MeSH Terms
Bayes Theorem
Bird Fancier's Lung / diagnosis
Diagnostic Errors* / statistics & numerical data
Fatal Outcome
Intensive Care Units*
Middle Aged
Pulmonary Edema / diagnosis
Systemic Inflammatory Response Syndrome / diagnosis
Comment In:
Crit Care Resusc. 2013 Mar;15(1):67   [PMID:  23432504 ]
Crit Care Resusc. 2013 Mar;15(1):67   [PMID:  23432506 ]

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