[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-657474-105":59,"doc-detail-657474-en":130},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":123,"head_meta":125,"extra_data":127,"updated_unix":129},105,"en","use-of-a-novel-modified-fishbone-diagram-to-analyze-diagnostic-errors","Use of a novel, modified fishbone diagram to analyze diagnostic errors","","Diagnostic errors are a critical subset of medical errors and often originate in individual cognition rather than purely system failures. Conventional patient-safety methods may therefore be insufficient, requiring a broader cognitive framework for thorough analysis. The fishbone diagram supports root cause analysis discussions, and the authors expanded it to capture both systems and cognitive errors. The paper explains how two medical centers applied the modified diagram to better support patient safety and education needs.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/use-of-a-novel-modified-fishbone-diagram-to-analyze-diagnostic-errors/657474/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/use-of-a-novel-modified-fishbone-diagram-to-analyze-diagnostic-errors/657474.png","ImageObject",300,407,{"name":92,"@type":93},"DoDO","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-10-26",true,{"@type":102,"interactionType":103,"userInteractionCount":14},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"Why do diagnostic errors require a different analysis framework?","Question",{"text":112,"@type":113},"Diagnostic errors often stem from faults in individual cognition, so purely system-focused approaches may miss important contributors. A broader cognitive framework is needed for comprehensive analysis.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What is the modified fishbone diagram used for?",{"text":117,"@type":113},"It supports root cause analysis discussions by structuring contributing factors. The modification explicitly reflects both systems errors and individual cognitive errors.",{"name":119,"@type":110,"acceptedAnswer":120},"How was the modified diagram applied in practice?",{"text":121,"@type":113},"The paper describes two medical centers that used the diagram to approach diagnostic errors in ways designed to meet their patient safety and educational objectives.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},657474,1792980648,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":14,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":29,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":129,"read_time":143},962093270745,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Open Access  \nJames B. Reilly, Jennifer S. Myers* , Doug Salvador and Robert L. Trowbridge  \nUse of a novel, modified fishbone diagram to analyze diagnostic errors  \nAbstract: Diagnostic errors comprise a critical subset of medical errors and often stem from errors in individual cognition. While traditional patient safety methods for dissecting medical errors focus on faulty systems, such methods are often less useful in cases of diagnostic error, and a broader cognitive framework is needed to ensure a comprehensive analysis of these complex events. The fishbone diagram is a widely utilized patient safety tool that helps to facilitate root cause analysis discussions. This tool was expanded by the authors to reflect the contributions of both systems and individual cognitive errors to diagnostic errors. We describe how two medical centers have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets the patient safety and educational needs of their respective institutions.  \nKeywords: cognitive error; diagnostic error; fishbone diagram; root cause analysis; systems error.  \n*Corresponding author: Jennifer S. Myers, MD, Associate Professor of Clinical Medicine, Department of Medicine, Associate Designated Institutional Official for Quality and Safety, Graduate Medical Education, Director of Quality and Safety Education, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Penn Tower, Suite 2009, Philadelphia, PA 19104, USA,  \nPhone: +(215)-662-2729, Fax: +(215) 662-6250, [E-mail: jennifer.myers@uphs.upenn.edu](E-mail: jennifer.myers@uphs.upenn.edu)  \nJames B. Reilly: Associate Program Director, Internal Medicine Residency Allegheny General Hospital-West Penn Hospital Educational Consortium, Pittsburgh, PA, USA; and Assistant Professor of Medicine, Temple University School of Medicine, Philadelphia, PA, USA  \nDoug Salvador: Vice President, Medical Affairs, Baystate Medical Center, Springfield, MA, USA; and Assistant Professor of Medicine, Tufts University School of Medicine, Boston, MA, USA  \nRobert L. Trowbridge: Assistant Professor of Medicine, Tufts University School of Medicine, Departments of Medicine and Medical Education, Maine Medical Center, Portland, ME, USA  \nIntroduction  \nThe publication of the Institute of Medicine report “To Erris Human” in 1999 increased recognition of preventable  \nmedical errors and catalyzed the development of the patient safety movement [1]. Along with improvements in the safety of healthcare systems, there has emerged an increasing appreciation of the importance of diagnostic error in causing patient harm [2, 3]. Studies suggest an overall diagnostic error rate as high as 8%–15% with 17% of adverse events in hospitalized patients being attributable to diagnostic error [4, 5]. Yet despite the high prevalence and increasing profile of diagnostic errors, the best means of preventing and responding to them remains unknown [6].  \nOne source of difficulty in addressing diagnostic error is the complexity of the underlying causative factors, with one study identifying an average of six contributory factors per error [7] . Further, there exist interdependencies and interactions between the imperfect human cognition and an imperfect work environment that complicate diagnostic error conversations [8, 9]. While physicians are becoming more comfortable discussing system factors that contribute to error, many have a limited understanding of the cognitive processes that underlie the diagnostic method and less comfort in acknowledging and learning from their own cognitive errors since they are by definition“personal” as opposed to being caused by “the system”.  \nThus, there is a need among both medical educatorsand patient safety experts for a structured approach to the analysis of diagnostic errors that accounts for their high degree of complexity. Root cause analysis (RCA) is one potential method of doing so. A recent study has described attempt","cbCaieqmzaWR1st6","https://ap.wps.com/l/cbCaieqmzaWR1st6","pdf",376690,"English","# Introduction\n## Applications for patient safety\n# Root cause analysis needs for diagnostic error\n## Modified fishbone diagram rationale","[{\"question\":\"Why do diagnostic errors require a different analysis framework?\",\"answer\":\"Diagnostic errors often stem from faults in individual cognition, so purely system-focused approaches may miss important contributors. A broader cognitive framework is needed for comprehensive analysis.\"},{\"question\":\"What is the modified fishbone diagram used for?\",\"answer\":\"It supports root cause analysis discussions by structuring contributing factors. The modification explicitly reflects both systems errors and individual cognitive errors.\"},{\"question\":\"How was the modified diagram applied in practice?\",\"answer\":\"The paper describes two medical centers that used the diagram to approach diagnostic errors in ways designed to meet their patient safety and educational objectives.\"}]","Use of a novel, modified fishbone diagram to analyze diagnostic errors | PDF",15]