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Improving Clinical Reasoning, Reducing Diagnostic Errors

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    Patient safety is a pertinent issue as compromised patient safety can lead to numerous dire consequences including unnecessary patient morbidity and mortality, demoralized staff's enthusiasm and tarnished institution's reputation.  One particular factor affecting patient safety is diagnostic errors. Illuminating the blind spot of diagnostic errors and improving diagnosis in health care may require a significant re-envisioning of the diagnostic process. This is because diagnostic error is a complex and multifaceted problem. One issue that increases the risk of diagnostic errors is cognitive biases. To address this challenge and to improve diagnosis for the patient, this course will address the complexity of clinical decision making and recommend strategies to minimize cognitive biases in order for one to become a better clinician and a decision-maker.



     Professor Dr. Kamarudin Bin Kana

    Diagnosis is a high-risk area for errors in primary care. Therefore, it is crucial for a clinician to have self-reflection and awareness of cognitive biases to minimize diagnostic errors. This course will guide you to construct good clinical reasoning and to minimize errors. 

     Professor Dr. Kamarudin Bin Kana 

    Dean
    Faculty of Medicine and Health Sciences
    Universiti Malaysia Sarawak (UNIMAS)

    [View his profile on UNIMAS experts]

     Dr. Nariman Singmamae                                                                                                                                      

    Correct and timely diagnosis relies on many factors, including knowledge, experience, and skill of a clinician and decision-maker. Therefore, it is crucial to have an excellent clinical judgment and learn strategies to minimize diagnostic errors. I hope by completing this course, you will become a better clinician and decision-maker in future. 

     Dr. Nariman Singmamae                                                                                                                          

    Deputy Dean
    Undergraduate and Student Development
    Faculty of Medicine and Health Sciences
    Universiti Malaysia Sarawak (UNIMAS)

    [View her profile on UNIMAS Experts]


     Professor Dr. Chew Keng Sheng

    Prof Dr. Chew Keng Sheng is a professor of medicine in the Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak (UNIMAS). He obtained his MD in 1999 from the School of Medical Sciences, Universiti Sains Malaysia (USM) and is a trained emergency physician, after obtaining his clinical Master of Medicine (Emergency Medicine) from the School of Medical Sciences, USM. In 2018, he obtained his PhD in medical education, with the focus on the area of developing a metacognitive mnemonic checklist to mitigate cognitive biases in clinical decision from the School of Health Education, Maastricht University, Netherlands. Prior to working in UNIMAS, he was a senior lecturer in the School of Medical Sciences, USM for 9 years from 2007 - 2015.

    [View his profile on UNIMAS Experts]

     Dev Nath Kaushal

     RN (M'sia), Dip. (Nursing), PGDiP Teaching and Learning (UNIMAS), AEMTC (KKM, M'sia), BSc. Nursing (Monash, Aus),   Msc. Nursing (Northumbria, UK)

    Dev is currently a lecturer with the Department of Nursing, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak (UNIMAS) and is also heading the Clinical Simulation Centre of the faculty. He is specialized in emergency and trauma nursing and is also a certified instructor for first aid, basic life support (BLS) and advanced cardiovascular life support (ACLS).

    Before embarking into academia, he served in the Emergency and Trauma Department where he was also engaged in medical evacuation, retrieval, and repatriation services. He was also involved in numerous other committees, including the hospital's code blue, disaster management and policy and procedure committee.

     [View his profile on UNIMAS Experts]


     Natasha Binti Anas

    Registered Nurse (RN)
    Currently pursuing Masters in Nursing Education


     Margeret Sanai

    Registered Nurse (RN)
    Currently pursuing Masters in Nursing Education


  • Lesson 1: Introduction to Patient Safety

    In this lesson, the learner will learn about the sources of errors that may compromise patient safety in the hospital, particularly in the context of emergency department as well as the impact of diagnostic errors on patient safety. The learners will also learn about the influence of the clinician’s thought processes on patient safety.

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    By the end of this lesson, the learners will be able to

    1. Describe the WHO-International Classification for Patient Safety (WHO-ICPS) conceptual framework of patient safety and patient safety culture
    2. Describe the sources of errors that can affect patient safety
    3. Be aware of the tendency for blame culture when things go wrong
    4. Explain the Swiss-cheese model for the manifestation of active diagnostic errors
    5. Perform root cause analysis using the Ishikawa fish bone diagram and the 5 'Why's approach
    6. Apply the 7 'M's, the London Protocol of system analysis of clinical incidents and the 7 groups of 'waste' ('muda') as groups of causes in the fish bone diagram

  • Lesson 2: Dual Process Theory of Thinking

    In this lesson, the learners will learn about the importance of our cognitive processes in influencing our clinical decisions. Specifically, the dual process theory of thinking as a conceptual model for reasoning will be explained in details.  Models of clinical reasoning will then be described. Nonetheless, the dual process theory of thinking is not without its limitations and potential misconceptions. One of these misconceptions will be described. Despite its limitations and potential misconceptions, dual process theory of thinking is still a useful model to describe clinical reasoning.

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    By the end of this lesson, the learners will be able to

    1. Describe the concept of dual process theory of thinking
    2. Identify the interplay of System 1 and System 2 cognitive processes of the dual process theory in clinical setting as well as everyday life
    3. Describe the hypothetico-deductive model for clinical reasoning
    4. Describe the limitations and misconception of the dual process theory of thinking

  • Lesson 3: Cognitive Errors (Part 1)

    In this lesson, the learners will learn about the classes of cognitive errors or cognitive biases. Cognitive errors or biases refer to our predisposition to react in a way that deviates from our rationality. In particular, the classification of cognitive biases by Campbell et al (2007) will be adapted in this module.

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    By the end of this lesson, the learners will be able to

    1. list the classes of cognitive biases
    2. describe and give examples of cognitive biases in each of these classes of cognitive biases

  • Lesson 4: Strategies to Minimize Cognitive Biases (Part 1)

    In this lesson, a summary on the important cognitive errors learned in the previous lesson will first be presented. The learners will then learn about the affective factors that may increase the risk or vulnerability of clinicians in committing cognitive errors. In particular, the learners will learn about the four types of patients that many clinicians dread to see, and thus, increases their propensity to cognitive errors when managing these types of patients. The learners will also learn about the importance of maintaining the day-sleep cycle and the effects of sleep deprivation. And finally, a discussion on the challenges in implementing strategies to minimize cognitive errors will be outlined.

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    By the end of this lecture, the learners will be able to
    1. Outline strategies to minimize cognitive biases in clinical decisions
    2. Describe the challenges of implementing cognitive debiasing strategies in clinical setting

  • Lesson 5: Strategies to Minimize Cognitive Biases (Part 2)

    In this final lesson, the different strategies of minimizing cognitive errors will be outlined. The learners will be directed to read further on these strategies in the recommended reading materials. The challenges in implementing strategies to minimize cognitive errors as well as the importance of metacognition will be delineated.

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    At the end of this lecture, the learners will be able to

    1. Outline the high risk situations that increase our risk of committing cognitive errors
    2. Describe metacognition and its importance in monitoring our thinking process
    3. Apply a mnemonic checklist called the TWED checklist to minimize cognitive biases in clinical decision making

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