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FAQ: Minimising diagnostic error – strategies to support your registrar

What is the “trifecta” of skills?

The “trifecta” refers to the interconnectedness of clinical reasoning, the management of uncertainty, and the reduction of diagnostic error. Good reasoning and effective management of uncertainty lead to fewer errors.

Will the discussion cover how to manage errors after they occur?

No, the discussion will not focus on the management of errors after they have occurred. However, it will emphasise the importance of open discussions about errors as learning opportunities and point to resources like Medical Defence Organisation Fact Sheets.

What is diagnostic error?

Diagnostic error involves both failing to establish an accurate and timely diagnosis and failing to communicate that explanation effectively to the patient.

How common is diagnostic error in medical practice?

Diagnostic error is a significant issue, accounting for a substantial portion (around a third) of medical claims.

How can case studies be used in teaching registrars?

Case studies provide practical examples for registrars to analyse clinical reasoning, identify potential errors, and discuss strategies for improvement.

 Supervisors can:

  • Facilitate discussions about clinical reasoning and diagnostic error.
  • Use case studies to analyse decision-making.
  • Encourage reflection on clinical encounters.
  • Provide feedback on performance.
  • Create a safe environment for discussing errors and uncertainty.

The main categories are:

  • Presentation factors (how the illness presents)
  • Undifferentiated illness (early, vague symptoms)
  • Atypical presentations of common diseases
  • Rare conditions
  • Patient factors
  • Difficulty communicating
  • Complex medical histories
  • Non-compliance with investigations or treatment
  • Self-labeling or misattributing symptoms
  • Inadequate follow-up.
  • Patient delays in seeking further care.
  • Doctor factors
  • Lack of knowledge or experience
  • Cognitive biases (e.g., confirmation bias, overconfidence bias)
  • Communication barriers
  • Time pressure and fatigue
  • “HALT” factors (Hungry, Angry, Late, Tired) System factors
  • Issues with appointment scheduling and access
  • Inadequate record-keeping systems
  • Lack of follow-up and recall systems
  • Walk-in or urgent care settings that disrupt continuity of care

    • No, diagnostic errors often result from a combination of factors. The “Swiss cheese model” illustrates how multiple factors can align to create an opportunity for error.

    Cognitive biases are flawed thinking patterns that can lead to errors in judgment and decision-making.

    • Confirmation bias: Seeking or interpreting information that confirms existing beliefs.
    • Overconfidence bias: Overestimating one’s own knowledge or abilities.
    • Availability heuristic: Overemphasizing recent or memorable cases.
    • Anchoring bias: Fixating on initial information and failing to adjust appropriately.
    • Awareness: Recognizing and acknowledging one’s own biases.
    • Metacognition: Thinking about one’s own thinking process.
    • Seeking diverse perspectives: Consulting with colleagues or considering alternative explanations.
    • Using decision support tools: Checklists, guidelines, and algorithms can help mitigate bias.

    The diagnostic pause is a brief period during the consultation where the clinician intentionally stops to reflect on the case, consider potential diagnoses, and plan the next steps.

    It allows the clinician to:

    • Organise their thoughts.
    • Identify potential biases.
    • Consider alternative diagnoses.
    • Avoid premature closure.
    • Formulate a safe and effective management plan.

    Clinicians can:

    • Take a few moments to think and make notes.
    • Use phrases like, “Let me just think about this for a moment.”
    • Explain to the patient that they are taking time to consider the case carefully.

    ICE stands for Ideas, Concerns, and Expectations. These questions help explore the patient’s perspective:

    • Ideas: What do you think might be causing your symptoms?
    • Concerns: What are you most worried about?
    • Expectations: What are you hoping we can achieve today?

    Rational test ordering involves selecting investigations that are most likely to benefit the patient while minimizing harm and unnecessary costs.

    Resources include:

    • Clinical guidelines (e.g., Therapeutic Guidelines, Health Pathways)
    • The BMJ paper on how GPs diagnose
    • The RACGP Clinical Reasoning Guide

    Gut feelings are intuitive senses of unease or concern about a patient. They can be valuable signals that warrant further investigation or attention.

    These include:
  • Thorough history and examination.
  • Appropriate use of investigations.
  • Seeking second opinions.
  • Open communication with patients.
  • Reflective practice.
  • Seeking help from colleagues or specialists.
  • Using checklists.
  • Effective communication with patients.
  • Utilising recall and reminder systems.
  • Keeping a personal notebook for tracking patients.
  • Employing safety netting techniques.

    • AI has the potential to assist with tasks like documentation and data analysis. However, there are concerns about its impact on clinical reasoning and the potential for bias. The RACGP recommends against using AI scribes for GPT1 registrars.

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    Date reviewed: 19 April 2025

    Please note that while reasonable care is taken to provide accurate information at the time of creation, we frequently update content and links as needed. If you identify any inconsistencies or broken links, please let us know by email.
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