Checklists to Reduce Diagnostic Errors
John W. Ely, MD, Mark L. Graber, MD, and Pat Croskerry, MD, PhD
evaluation. The purpose of this article is often be traced to physicians’ cognitive to argue for the further investigation and describes three types of checklists: (1) a revision of these initial attempts to apply general checklist that prompts physicians checklists to the diagnostic process. The to optimize their cognitive approach, (2) basic idea behind checklists is to provide to error, but little is known about how to a differential diagnosis checklist to help an alternative to reliance on intuition and of diagnostic error—failure to consider the correct diagnosis as a possibility, and Editor’s Note: A commentary on this article appears they are well integrated in the workflow, Cognitive Processes in Diagnosis
suggestions include reflective practice8,9 recognize flaws in the intuitive “thinking” psychology related to the “dual-process” 1).18 This model proposes two basic modes and more likely to result in patient harm than are other types of medical errors.3,4 Given their success in other settings, it is reflexive, intuitive, and may operate at a subconscious level. We perform many tasks might help reduce diagnostic errors.
Checklists are used by airline pilots in all system-based problems are relatively easy routinely until the crash of a Boeing 299 they are repeated on a regular basis, these release the elevator locks.11 Checklists are subconscious level, and if everything is as it Dr. Ely is professor, Department of Family Medicine,
University of Iowa, Iowa City, Iowa.
used by other high-risk, high-reliability seems, we perform well. In contrast, Type 2 processes are analytic, slow, and deliberate.
Dr. Graber is chief of medicine, Department of
Veterans Affairs Hospital, Northport, New York, andprofessor and associate chair, Department of Internal Medicine, State University of New York, Stony Brook, Dr. Croskerry is professor of emergency medicine,
Dalhousie University, Halifax, Nova Scotia, Canada.
intensive care unit staff use checklists to Correspondence should be addressed to Dr. Ely, Department of Family Medicine, 01291-D, PFP, clinical situations that seem familiar, we University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242; telephone: (319) 384-7533; fax: (319) 384-7822; e-mail: john- surgical deaths by half after introducing a checklists prove effective. For diagnosis, The purpose of this article is to describe a generic checklists could force a reflective First published online January 18, 2011doi: 10.1097/ACM.0b013e31820824cd potential role for checklists in avoiding check, and specific checklists could force Supplemental digital content for this article isavailable at
Academic Medicine, Vol. 86, No. 3 / March 2011 “upstream” problems—those involving previous encounters—such assuccumbing to the framing bias imparted RECOGNIZED
it is proposed and communicated, to theextent that subsequent physicians may Calibration†
discount or fail to consider other possible Processor
“groupthink,” in which the chances oferror increase when the impressions of RECOGNIZED
Figure 1 A model for diagnostic reasoning based on dual-process theory. Adapted with
permission from Croskerry P. A universal model for diagnostic reasoning. Acad Med. 2009;84:1022–1028. Type 1 thinking can be influenced by multiple factors, many of them subconscious Perform a focused and purposeful
(emotional polarization toward the patient, recent experience with the diagnosis being physical exam. The initial hypotheses
considered, specific cognitive or affective biases), and is therefore represented as multiple- channeled, whereas Type 2 processes are, in a given instance, single-channeled and linear. Type 2override of Type 1 (executive override) occurs when physicians take a time-out to reflect on their thinking, possibly with the help of checklists. In contrast, Type 1 may irrationally override Type 2 (dysrationalia override) when physicians insist on going their own way (e.g., ignoring evidence- based clinical decision rules that can usually outperform them).
special attention. However, we must alsolook for signs that might suggest alternate * “Dysrationalia” denotes the inability to think rationally despite adequate intelligence.68† “Calibration” denotes the degree to which the perceived and actual diagnostic accuracy correspond.
Checklists could help us resist the biases errors in hospitals, clinics, and emergency Generate and differentiate initial
hypotheses with further history,
physical exam, and diagnostic tests.
insultingly obvious (e.g., “Obtain your improving diagnostic reasoning.2,10 Using own complete history”), but their routine problems related to diagnostic testing,26 for most physicians. After all, pilots no their copilots to release the elevator locks.
• consider a comprehensive differential The general checklist
posttest period, occurring at rates of 10% reproducible approach to diagnosis.21 List 1 offers an example of such a checklist.
• develop strategies to avoid predictable Pause to reflect—take a diagnostic
“time-out.” Short of seeking a second
• recognize our altered mood states that arise from fatigue, sleep deprivation, or plausibility of the working diagnosis may be our best tool to avoid error.8,9 The two context errors and premature closure.5,26 Context errors arise when a critical signalis distorted by the background against Diagnostic Checklists
Obtain your own complete medical
which it is perceived.24 A typical context Here, we describe three types of checklists history. There is no substitute for
Academic Medicine, Vol. 86, No. 3 / March 2011 Table 1
Cognitive Biases and Failed Heuristics Addressed by Diagnostic Checklists
Bias or heuristic
Role of checklist
The tendency to perceptually lock on to salient features Prompt physician to consider diagnoses other than the of the patient’s presentation too early in the diagnostic process and failing to adjust this impression in light oflater information.
The disposition to judge things as being more likely or Prompt physician to consider diagnoses other than frequently occurring, if they readily come to mind.
The tendency to ignore the true prevalence of a Remind physician of the relative prevalence of diseases disease, either inflating or reducing its base rate and in primary care for the patient’s complaint.
The decision-making process ends too soon; the Prompt physician to reopen the diagnostic process and diagnosis is accepted before it has been fully verified.
consider alternative diagnoses before discharging the “When the diagnosis is made, the thinking stops.” The physician looks for prototypical manifestations of Prompt physician to consider causes for the symptoms disease (pattern recognition) and fails to consider other than the ones that readily fit the pattern.
The tendency to call off a search once something is Prompt physician to consider additional causes of the The failure to elicit all relevant information in Prompt physician to ask questions that might confirm establishing a differential diagnosis.
The critical signal is distorted by the background Encourage physician to rethink assumptions and * Source: Croskerry P. Cognitive and affective dispositions to respond. In: Croskerry P, Cosby K, Schenkel S, Wears R, eds. Patient Safety in Emergency Medicine. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009:219 –227.
other decisions may take priority, such as patient’s presentation often changes over Differential diagnosis checklists
diagnostic errors is our failure to consider and write “NYD” (not yet diagnosed) in • Consider the opposite: “Why can’t this be something else?” Tests that rule out diagnostic label until our certainty is high • Use “prospective hindsight”: Derived Embark on a plan, but acknowledge
Proposed General Checklist for

uncertainty and ensure a pathway for
follow-up.37,38 We often just play the
• Obtain your own complete medical history.
• Perform a focused and purposeful physical Certainty is not a realistic possibility. The correct diagnosis often emerges over time as test results become available or as the differentiate these with additional history, patient’s symptoms and signs evolve. This physical exam, and diagnostic tests.
• Apply decision support tools: A growing longitudinal aspect of diagnosis mandates • Pause to reflect—take a diagnostic “time that we reconsider an initial diagnosis at diagnosis generators are available, such as ⅙ Was my judgment affected by any other uncertainties, and lay out a concrete plan ⅙ Do I need to make the diagnosis now, or ensuring follow-up is a strategy that can help improve the reliability of diagnosis uncertainty and ensure a pathway for Academic Medicine, Vol. 86, No. 3 / March 2011 highlighted in List 2 and detailed in the dizziness, and so on. The checklists were revised during two years of use in clinic.
to consider a comprehensive list of causes of the differential diagnosis checklist is differential diagnosis checklists, but one of the authors (J.E.) has noted anecdotal checklists highlight diagnoses that should not be missed and those that are, in fact, checklists in practice. For example, a 90- anatomy,43,45,46,48 pathophysiology,41,45 after two albuterol nebulizer treatments, dyspnea. She had been seen four daysearlier with a “COPD exacerbation” and Example of Differential Diagnosis
to cover 100% of presenting complaints.
Sinus tachycardia
checklists. And within each checklist, our goal was to cover at least 99% of patients • Chronic obstructive pulmonary disease • Pregnancy (10 to 20 beats per minute at such as constipation and breast lumps.
that did not alter the initial diagnosis and withdrawal, bupropion, caffeine, cilostazol, cocaine, ephedrine, epinephrine,isoproterenol, nicotine, tobacco)† Cognitive forcing checklists for specific
“pneumococcal pneumonia,” “klebsiella Checklists can serve as cognitive forcing “right-upper-quadrant pain,” “right- because we wanted to avoid redundancy.
until the card is removed. Thus, the error avoided. If the checklist is always built into diagnostic thinking, then it becomes generic or specific. In the generic sense, “ROWS” (rule out worst-case scenario) • Postural orthostatic tachycardia syndrome possibilities always receive consideration.
• Chronic nonparoxysmal sinus tachycardia checklist at the time of admission to help In the specific sense, checklists may help determine whether further history taking, avoid predictable pitfalls for particular * “Don’t-miss” diagnosis.
† Commonly missed diagnosis.
Academic Medicine, Vol. 86, No. 3 / March 2011 address treatment rather than diagnosis.
Example of a Disease-Specific
Cognitive Forcing Checklist
Ankle injury
enough face validity to make such testing questioned the ethics of allowing patients to participate in a usual-care arm (i.e., no safety intervention) in clinical trials of ⅙ Peroneal tendon syndromes (tendinitis, checklists before adopting them. Instead, most likely for a particular patient.
⅙ Consider stress films for ankle stability not been widely adopted in practice,52,53 checklists may have a greater potential for harm than preflight or surgical checklists.
knowledge base,6 they can be difficult to For example, they could lead to excessive incorporate into the workflow,6,54–56 and consultation or needless testing (although most serious errors result from doing too Other interventions similar to checklists ⅙ Missed neurovascular injury (suspect if ⅙ Missed associated fracture (especially (mental checklists).62 These interventions learned not to rely on their memories. In contrast, physicians value superior recall ⅙ Missed Maisonneuve fracture (proximal organizational structures that differ from ⅙ Missed Achilles tendon rupture (partial or than mental crutches, reflective thought, Limitations of checklists
⅙ Missed complex regional pain syndromes Recent success in adapting preflight-style stories, but they don’t make great health checklists for diagnosis may be a “bridge too far.” The analogy between actionable forcing strategies will inevitably focus on intensive care units, or even airplanes.
procedures in diagnosis is not tight.
Thoughts are less tangible than actions, Checklists could produce a false sense ofreassurance that leads to complacency, Further Considerations and
whether they have been completed. Inboth medical and nonmedical settings, checklists are read aloud by teams rather checklists as a concept that might reduce aspects of care unrelated to diagnosis.
diagnosis is usually silent, lonely work, Similar concerns were raised with clinical and a natural pause point11 to review the algorithms. It was feared that physicians kinds of checklists, which we have used in checklist, such as before takeoff or before data to support these concerns whenalgorithms were studied in practice.65,66 Related studies
Diagnostic support tools include practice checklists in this article were not derived affective state. But rather than unfocused Academic Medicine, Vol. 86, No. 3 / March 2011 “thunderclap” headache, “worst-ever” 12 Karl R. Briefings, checklists, geese, and
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