The impact of diagnostic errors on patient safety in medicine is increasingly being recognized. Despite the current progress in patient safety research, the understanding of such errors and how to prevent them is inadequate. Preliminary research suggests that diagnostic errors have both cognitive and systems origins. Situational awareness is a model that is primarily used in aviation human factors research that can encompass both the cognitive and the systems roots of such errors. This conceptual model offers a unique perspective in the study of diagnostic errors. The applicability of this model is illustrated by the analysis of a patient whose diagnosis of spinal cord compression was substantially delayed. We suggest how the application of this framework could lead to potential areas of intervention and outline some areas of future research. It is possible that the use of such a model in medicine could help reduce errors in diagnosis and lead to significant improvements in patient care. Further research is needed, including the measurement of situational awareness and correlation with health outcomes.
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- SA, situational awareness
- SAGAT, Situation Awareness Global Assessment Technique
- diagnostic errors
- situational awareness
- human factors
- decision making
Funding: HS is the recipient of an NIH K12 Mentored Clinical Investigator Award grant number K12RR17665 to Baylor College of Medicine; LAP is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar (grant number 045444) and a recipient of the American Heart Association Established Investigator Award (grant number 0540043N); and EJT is supported by grant number 1PO1HS1154401 from the Agency for Healthcare Research and Quality
Competing interests: none.
The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. HS is the responsible author.
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