Behind heart disease and cancer, medical error is now listed as one of the leading causes of death. Of the many medical errors that may lead to injury and death, diagnostic failure is regarded as the most significant. Generally, the majority of diagnostic failures are attributed to the clinicians directly involved with the patient, and to a lesser extent, the system in which they work. In turn, the majority of errors made by clinicians are due to decision making failures manifested by various departures from rationality. Of all the medical environments in which patients are seen and diagnosed, the emergency department is the most challenging. It has been described as a "wicked" environment where illness and disease may range from minor ailments and complaints to severe, life-threatening disorders. The Cognitive Autopsy is a novel strategy towards understanding medical error and diagnostic failure in 42 clinical cases with which the author was directly involved or became aware of at the time. Essentially, it describes a cognitive approach towards root cause analysis of medical adverse events or near misses. Whereas root cause analysis typically focuses on the observable and measurable aspects of adverse events, the cognitive autopsy attempts to identify covert cognitive processes that may have contributed to outcomes. In this clinical setting, no cognitive process is directly observable but must be inferred from the behavior of the individual clinician. The book illustrates unequivocally that chief among these cognitive processes are cognitive biases and other flaws in decision making, rather than knowledge deficits.

v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.

This case-based book illustrates and explores common cognitive biases and their consequences in the practice of medicine. The book begins with an introduction that explains the concept of cognitive errors and their importance in clinical medicine and current controversies within healthcare. The core of the book features chapters dedicated to particular cognitive biases; cases are presented and followed by a discussion of the clinician's rationale and an overview of the particular cognitive bias. Engaging and easy to read, this text provides strategies on minimizing cognitive errors in various medical and professional settings.

Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.

This book exposes the dangerously imperfect forensic evidence that we rely on for criminal convictions. "That's not my fingerprint, your honor," said the defendant, after FBI experts reported a "100-percent identification." The FBI was wrong. It is shocking how often they are. Autopsy of a Crime Lab is the first book to catalog the sources of error and the faulty science behind a range of well-known forensic evidence, from fingerprints and firearms to forensic algorithms. In this devastating forensic takedown, noted legal expert Brandon L. Garrett poses the questions that should be asked in courtrooms every day: Where are the studies that validate the basic premises of widely accepted techniques such as fingerprinting? How can experts testify with 100-percent certainty about a fingerprint, when there is no such thing as a 100 percent match? Where is the quality control at the crime scenes and in the laboratories? Should we so readily adopt powerful new technologies like facial recognition software and rapid DNA machines? And why have judges been so reluctant to consider the weaknesses of so many long-accepted methods? Taking us into the lives of the wrongfully convicted or nearly convicted, into crime labs rocked by scandal, and onto the front lines of promising reform efforts driven by professionals and researchers alike, Autopsy of a Crime Lab illustrates the persistence and perniciousness of shaky science and its well-meaning practitioners.

The Psychology of Death Investigations outlines definitively how behavioral evidence can often provide the necessary components and "missing pieces" to complement physical evidence as an essential tool for incident reconstruction. In order to determine the direction of an investigation and to prioritize leads, if necessary, death investigators must establish the manner of a death: natural, accident, homicide or suicide. The most overlooked aspect of death investigation is the psychological dimension, which can provide unique leads, correct false assumptions, enhance investigative awareness, and solve cases in surprising ways. In an estimated 10–20% of cases, the manner of death cannot be determined, or worse, has been erroneously categorized. Since many jurisdictions can’t afford behavioral consultants, this book has been written to provide practical information for a basic psychological analysis. If the circumstances surrounding a death are equivocal, psychological consultants can compile information retrospectively about a deceased person’s mental state and possible motive to assist with unravelling ambiguity about the manner of death. This is the primary function of a psychological autopsy, and, as such, this is the first book of its kind dedicated solely to the topic. In the event that the manner of death is determined to be a homicide, behavioral profiling can help to focus the potential pool of suspects. Professionals and students alike will benefit from the exercise of cognitive awareness and the application of psychological logic presented. Psychologists, medical examiners, coroners, attorneys, fraud examiners, law enforcement personnel, death and homicide investigators, and students enrolled in criminal profiling, forensic psychology, and criminal justice programs will find this text to be a compelling and insightful reference to add to their professional toolkit.

In the past several years, forensic pathology has been the focus of multiple television programs and bestselling novels and, in some respects, has become a glamorous profession. The reality is far different: In fact, autopsy has been the focus of considerable controversy since its inception. This book focuses on that reality and reveals just what we really do learn from the dead. Despite a recent decline in autopsy rates, its merits are actually considerable. In addition to determining the cause of death in criminal cases, it plays a role in establishing public trust in medicine, provides therapeutic value for surviving family members, and benefits the population as a whole by allowing for surveillance and detection of certain disease processes. Autopsy remains a mainstay of medical education, affording a unique opportunity to perform many types of research. This guide dispels myths and is an invaluable resource for families who are faced with decisions regarding autopsy.