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Table of Contents   
Year : 2012  |  Volume : 5  |  Issue : 1  |  Page : 1-2
Clinical errors

Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India

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Date of Web Publication12-Mar-2012

How to cite this article:
Kothari SS. Clinical errors. Ann Pediatr Card 2012;5:1-2

How to cite this URL:
Kothari SS. Clinical errors. Ann Pediatr Card [serial online] 2012 [cited 2022 Jan 27];5:1-2. Available from:

Do you remember your worst clinical decision? Could you analyze and understand the causal factors? Doctors do not seem to remember their errors. [1] But errors in clinical decisions are rarely unifocal in origin. [2] Pediatric cardiac services, being team dependent, may be more prone to errors. Consider the catastrophic event of endotracheal tube block in the postoperative period that was not adequately managed by the attending nurse; but the child had required unusually prolonged ventilation as it was a redo surgery, and the redo was needed because the surgeon did not pick up the diagnostic error committed by the cardiologist. In other words, one needs not only trained individuals but also systems with checks and balances and buffers for providing optimal health care delivery.

There is a voluminous and growing literature on clinical decision making and clinical errors, both in the diagnosis and the management arena of patient care. Very little is formally taught regarding decision making in undergraduate education.With increasing exposure and experience, we are expected to learn the art of decision making utilizing the information and knowledge base automatically. But two equally experienced clinicians, given the same data set, may draw different conclusions. It is interesting to analyze how we make decisions. We use rules of thumb or heuristics in decision making. [3] Similarly, lots of heuristics are utilized by the surgeons in their operative skills which are under recognized. [4] The rules of thumb or pattern recognition that routinely help in decisions, sometimes generate biases. There could be a number of biases, such as availability bias (diagnosing what is recalled in the mind quickly), representativeness bias (judging by similarity of symptoms), confirmation bias (testing to confirm but failing to test for the alternative possibilities), and anchoring bias (mind is anchored and does not change with new data) etc. For example, rare diseases are remembered more and may be over diagnosed, or the result of the previous operation of a particular disease may unfairly color the surgical decision of the current patient with that disease. Error may creep in when habitual thinking is used less mindfully or 'routinely'. But sometimes the traps are real. Clinicians use Occam's razor and try and fit every thing in a single disease whereas the patient may in fact have two diseases. But these are rare situations.

Contrary to simple logic, inadequate training or lack of skill are uncommon causes of lapse in clinical decisions once beyond the basic training. Rather, other cognitive factors are important. In a land mark study of clinical diagnostic errors, majority of errors were found to be cognitive errors, errors related to systems, or a combination of both. [5] In making medical diagnosis, inadequate context generation, faulty synthesis and premature closure of the case (not seeking enough data or getting biased towards presumed diagnosis) were common types of cognitive errors. This means that not understanding the problem in it's perspective, not appropriately weighing the available information and drawing the wrong conclusions could result despite potentially having information or knowledge of the issues at hand. On the system side, faulty policies and processes, and inadequate communication were dominant system errors in that study. [5] Error prone organizations are remarkable for having lack of clarity about the individual's role, for tolerating ambiguity and for getting job done around without initiating efforts to learn from the problems or improve processes. [6] Thus, good systems typically have accountability, open communications, internal audit, enthusiasm for small changes, trust and good will.

Further, in modern times, over-investigating, and over-treating are prevalent errors that are not easily recognized as such, and these errors may result from defensive medicine practices, cognitive biases, or unaudited systems. However, there could be errors beyond heuristics and systems, and clinical errors are not easy to eliminate. [7]

Experience (…of having erred in the past) may perhaps reduce but does not eliminate the cognitive errors, and errors of analytical thinking are equally common in senior and junior doctors. [7] There does not seem to be a particular error prone personality but overconfidence is a factor. [1] A dose of humility always keeps the clinician's in good shape. Of course the ultimate weapon for becoming an 'Oslerian clinician' is the quality of equanimity that would eliminate cognitive errors. It is an ideal goal to seek, even if it remains elusive. [8] It behoves clinicians to ponder over these issues and reflect if he/she is prone to a particular bias, if such a thing is possible, and also to be proactive to system faults in their own milieu. This exercise itself will generate self-audit and training.

The basic rules of medical decision making rest on common sense, evidence and discrimination. But in medicine, one always dabbles with uncertainty. It is a permanent lie to think that one day you would have all the facts available to you for making the best decisions. Thus, clinical errors would remain. Fortunately, in pediatric cardiology, the complexities of decision making is relatively less. Advances in imaging have demystified the anatomic diagnosis to a large extent. But the management issues are no less complex than in other branches. And sometimes we do not realize that the evidence base for many decisions that we routinely make in pediatric cardiac services is very limited.

The situation in cardiac surgical field is somewhat different. For congenital heart surgery, the learning curve is steeper. While biases and cognitive factors play a role in all decision making including those in the surgical field, the margin for error is small. Surgeons particularly need to be sensitive to self audit and in seeing the system failures. Sometimes even retraining might be required as demonstrated by the "de Leval" experiment where the famous surgeon went for retraining after a cluster of failures. [9] The importance of system failure was evident in the widely publicized "Bristol affair," where a high mortality prevailed in a cardiac centre for a variety of reasons despite seemingly competent people. [10] The "Bristol affair" is now almost forgotten in the western world but is worth a reminder.

As regards pediatric cardiac services, the situation in India and many other parts of the world may be quite hopelessly conducive for reenacting "Bristol affairs". Though there are centers of excellence attracting even medical tourism, significant heterogeneity prevails. The sociopolitical and economic developments have increased the patient population and many public health and private centers have started pediatric cardiac services. The demand supply equation and many other system constraints are much worse than optimally required. The practice of internal audit is not routine, almost non existent. It is mandatory that individual members of the team recognize the importance of self audit, and the leaders understand their responsibilities for smoothening the systems to the best possible extent, and learn from other's mistakes.The higher stoicism in our patients increase, and not decrease our responsibility. In matters of clinical errors, "to err is human, to repent divine, but to persevere is devilish." [11]

   References Top

1.Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121(5 Suppl): S2-23.  Back to cited text no. 1
2.Berner ES, Graber ML. Diagnostic error in medicine. Adv Health Sci Educ Theory Pract 2009;14 Suppl 1:1-112.  Back to cited text no. 2
3.Wegwarth O, Gaissmaier W, Gigerenzer G. Smart strategies for doctors and doctors-in-training: heuristics in medicine. Med Educ 2009;43:721-8.  Back to cited text no. 3
4.Tesar P. Heuristics in cardiothoracic surgery. ANZ J Surg 2008;78:1106-8.  Back to cited text no. 4
5.Graber M, Franklin N. Diagnostic errors in internal medicine. Arch Intern Med 2005;165:1493-9.  Back to cited text no. 5
6.Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med 2005:142:627-30.  Back to cited text no. 6
7.Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med Educ 2010;44:94-100.  Back to cited text no. 7
8.Osler W. Aequanimitas, With Other Addresses to Medical Students, Nurses and Practitioners of Medicine. 2nd ed. Philadelphia: Blackiston's Sons and Co; 1925. p. 1-13.  Back to cited text no. 8 Leval MR, François K, Bull C, Brawn W, Spiegelhalter D. Analysis of a cluster of surgical failures. Application to a series of neonatal arterial switch operations. J Thorac Cardiovasc Surg 1994;107:914-23; discussion 923-4.  Back to cited text no. 9
10.The Bristol Royal Infirmary Inquiry. Final report Available from: http//: [Last accessed on 2012 Jan 1].  Back to cited text no. 10
11.Apperson GL. In: Manser M, Curtis S. A Dictionary of Proverbs. Ware: Wordsworth Press; 2006. p. 175.  Back to cited text no. 11

Correspondence Address:
Shyam S Kothari
Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-2069.93702

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