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Title: Zebra in the intensive care unit: a metacognitive reflection on misdiagnosis.
Austin Authors: Gillon, Stuart A;Radford, Samuel T 
Affiliation: Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
Issue Date: 1-Sep-2012
Publication information: Critical Care and Resuscitation; 14(3): 216-20
Abstract: 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.
Gov't Doc #: 22963217
Journal: Critical Care and Resuscitation
Type: Journal Article
Subjects: 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
Appears in Collections:Journal articles

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