Understanding Diagnostic error: a scoping study of the role of ambiguity, uncertainty, and complexity in reasoning and error

The purpose of this research is to advance our understanding of reasoning processes related to diagnostic error, a major cause of adverse events in medicine. Adverse events (AEs) are frequent, costly, and represent a significant burden on our health care system. Of 2.5 million annual hospital admissions in Canada, an estimated 185,000 are associated with AEs, which cost approximately $750 million in health spending per year. Over 85% of AEs have consequences on patient health and well-being, and an estimated 40% are preventable. Despite policy and grassroots efforts to reduce AEs, mistakes in medicine persist. Diagnostic error (misdiagnosis) is the second largest cause of AEs, contributing to 10% of patient deaths. This suggests that, while physicians work within systems and teams, a large proportion of error can be attributed to the reasoning processes of individual clinicians. Failure to understand the nature of these processes leaves an important cause of medical error unaddressed. The Institute of Medicine (IOM, 2015) stated that diagnostic error is a threat to patient safety, a gap in clinician education, and a research and funding priority. The Royal College of Physicians and Surgeons of Canada (RC; the accreditation and certification body for specialist physicians in Canada) explicitly highlights the importance of individual reasoning processes in the 2015 CanMEDs physician competency framework, stating that physicians must “recognize and respond to the complexity, uncertainty, and ambiguity inherent in medical practice”. Further, the IOM reports the role of diagnostic uncertainty in poor resource use (i.e. over-testing) and error. However, despite the attention given to ‘ambiguity’, ‘uncertainty’, and ‘complexity’ in the 2015 IOM report and CanMEDs 2015, these concepts remain largely underspecified. This study will investigate how ambiguity, uncertainty, and complexity are conceptualized as factors that contribute to diagnostic error. Using scoping methodology to map definitions and understandings of these terms in the clinical reasoning literature, our analysis will include: i) a thematic analysis of the conceptualizations of ambiguity, uncertainty, and complexity as factors contributing to diagnostic error, and ii) a citation network analysis to map the relationships between different conceptualizations, theoretical frameworks and citations of influence. The team assembled is uniquely qualified to complete this project. MY is a researcher in clinical reasoning and assessment. FB, Associate Director (Assessment) for the RC, was a key member in developing CanMEDs 2015 and represents the knowledge user (RC). AT is a researcher with expertise in knowledge translation and an expert in scoping methodology. SD is a clinician, an expert in the field of clinical reasoning, and a consultant on the 2015 IOM Report. NT is an expert health science librarian. SL and VD are clinicians and researchers in clinical reasoning and assessment. This knowledge synthesis developed in conjunction with the RC, will provide theoretical and evidence-based foundations for training and assessment of clinical reasoning as an enabling competence for physicians. This work will contribute to developing targeted educational programs, effective policy implementation in medical education, and improved medical practice, as it links clinical reasoning, assessment, and the development of expertise in order to minimize the frequency of medical error in Canada.