Preventing diagnostic errors and the interaction of cognitive and system problems

Interesting post by Gordon Schiff at the Health Affairs Blog:

 This “systems vs. cognitive” polarity, so prevalent in analyses of error causation, strikes me as an highly artificial and false distinction.  If I am an emergency room physician taking a history to sort out a patient’s back pain and fail to elicit a key piece of information or consider a critical diagnosis because I am interrupted by a cardiac arrest in the next bed, is this a cognitive or system error?

All too often we don't even have time to think (cognition) let alone think about how we think (metacognition).


Via MedRants.