Jump to ContentJump to Main Navigation
Show Summary Details
More options …


Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / Singhal, Geeta / McDonald, Kathryn / Singh, Hardeep / Newman-Toker, David

Editorial Board: Basso , Daniela / Crock, Carmel / Croskerry, Pat / Dhaliwal, Gurpreet / Ely, John / Giannitsis, Evangelos / Katus, Hugo A. / Laposata, Michael / Lyratzopoulos, Yoryos / Maude, Jason / Sittig, Dean F. / Sonntag, Oswald / Zwaan, Laura

CiteScore 2018: 0.69

SCImago Journal Rank (SJR) 2018: 0.359
Source Normalized Impact per Paper (SNIP) 2018: 0.424

See all formats and pricing
More options …

Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error

Quentin Eichbaum
  • Corresponding author
  • Vanderbilt Pathology Education Research Group (VPERG), Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, TN, USA
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Brian AdkinsORCID iD: https://orcid.org/0000-0002-9480-2762 / Laura Craig-Owens
  • Vanderbilt Pathology Education Research Group (VPERG), Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, TN, USA
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Donna Ferguson
  • Vanderbilt Pathology Education Research Group (VPERG), Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, TN, USA
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Daniel Long / Aaron Shaver
  • Vanderbilt Pathology Education Research Group (VPERG), Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, TN, USA
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Charles Stratton
  • Vanderbilt Pathology Education Research Group (VPERG), Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, TN, USA
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
Published Online: 2018-12-04 | DOI: https://doi.org/10.1515/dx-2018-0089



Heuristics and cognitive biases are thought to play an important role in diagnostic medical error. How to systematically determine and capture these kinds of errors remains unclear. Morbidity and mortality rounds (MMRs) are generally focused on reducing medical error by identifying and correcting systems failures. However, they may also provide an educational platform for recognizing and raising awareness on cognitive errors.


A total of 49 MMR cases spanning the period 2008–2015 in our pathology department were examined for the presence of cognitive errors and/or systems failures by eight study participant raters who were trained on a subset of 16 of these MMR cases (excluded from the main study analysis) to identify such errors. The Delphi method was used to obtain group consensus on error classification on the remaining 33 study cases. Cases with <75% inter-rater agreement were subjected to subsequent rounds of Delphi analysis. Inter-rater agreement at each round was determined by Fleiss’ kappa values.


Thirty-six percent of the cases presented at our pathology MMRs over an 8-year period were found to contain errors likely due to cognitive bias.


These data suggest that the errors identified in our pathology MMRs represent not only systems failures but may also be composed of a significant proportion of cognitive errors. Teaching trainees and health professionals to correctly identify different types of cognitive errors may present an opportunity for quality improvement interventions in the interests of patient safety.

Keywords: cognitive bias; cognitive error; diagnostic error; mortality and morbidity rounds (MMR); pathology; systems failure


  • 1.

    Croskerry P. From mindless to mindful practice – cognitive bias and clinical decision making. N Engl J Med 2013;368:2445–8.PubMedCrossrefGoogle Scholar

  • 2.

    Orlander JD, Barber TW, Fincke BG. The morbidity and mortality conference: the delicate nature of learning from error. Acad Med 2002;77:1001–6.CrossrefPubMedGoogle Scholar

  • 3.

    Gregor A, Taylor D. Morbidity and mortality conference: its purpose reclaimed and grounded in theory. Teach Learn Med 2016;28:439–47.CrossrefPubMedGoogle Scholar

  • 4.

    Orlander JD, Fincke BG. Morbidity and mortality conference: a survey of academic internal medicine departments. J Gen Intern Med 2003;18:656–8.PubMedCrossrefGoogle Scholar

  • 5.

    Deis JN, Smith KM, Warren MD, Throop PG, Hickson GB, Joers BJ, et al. Transforming the morbidity and mortality conference into an instrument for systemwide improvement. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: new directions and alternative approaches (Vol. 2: culture and redesign). Rockville (MD) USA: Agency for Healthcare Research and Quality (US), 2008.Google Scholar

  • 6.

    Bechtold M, Scott S, Dellsperger K, Hall L, Nelson K, Cox K. Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety. Postgrad Med J 2008;84:211–6.CrossrefPubMedGoogle Scholar

  • 7.

    Higginson J, Walters R, Fulop N. Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? Br Med J Qual Saf 2012;21:576–85.CrossrefGoogle Scholar

  • 8.

    Stiegler M, Neelankavil J, Canales C, Dhillon A. Cognitive errors detected in anaesthesiology: a literature review and pilot study. Br J Anaes 2011;108:229–35.Google Scholar

  • 9.

    Mamede S, van Gog T, van den Berge K, Rikers RM, van Saase JL, van Guldener C, et al. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. J Am Med Assoc 2010;304:1198–203.CrossrefGoogle Scholar

  • 10.

    Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493–9.CrossrefPubMedGoogle Scholar

  • 11.

    Thiels CA, Lal TM, Nienow JM, Pasupathy KS, Blocker RC, Aho JM, et al. Surgical never events and contributing human factors. Surgery 2015;158:515–21.PubMedCrossrefGoogle Scholar

  • 12.

    Fandel T, Pfnür M, Schäfer S, Bacchetti P, Mast F, Corinth C, et al. Do we truly see what we think we see? The role of cognitive bias in pathological interpretation. J Pathol 2008;216:193–200.PubMedCrossrefGoogle Scholar

  • 13.

    Ryan A, Duignan S, Kenny D, McMahon CJ. Decision making in paediatric cardiology. Are we prone to heuristics, biases and traps? Pediat Cardiol 2018;39:160–7.CrossrefGoogle Scholar

  • 14.

    Mendel R, Traut-Mattausch E, Jonas E, Leucht S, Kane J, Maino K, et al. Confirmation bias: why psychiatrists stick to wrong preliminary diagnoses. Psychol Med 2011;41:2651–9.PubMedCrossrefGoogle Scholar

  • 15.

    Bal G, Sellier E, Tchouda SD, François P. Improving quality of care and patient safety through morbidity and mortality conferences. J Healthc Qual 2014;36:29–36.PubMedCrossrefGoogle Scholar

  • 16.

    Croskerry P. When I say… cognitive debiasing. Med Edu 2015;49:656–7.CrossrefGoogle Scholar

  • 17.

    Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121:S2–23.PubMedCrossrefGoogle Scholar

  • 18.

    Nakhleh RE. Patient safety and error reduction in surgical pathology. Arch Pathol Lab Med 2008;132:181–5.PubMedGoogle Scholar

  • 19.

    Pineda LA, Hathwar VS, Grant BJ. Clinical suspicion of fatal pulmonary embolism. Chest 2001;120:791–5.CrossrefPubMedGoogle Scholar

  • 20.

    Aaronson EL, Wittels KA, Nadel ES, Schuur JD. Morbidity and mortality conference in emergency medicine residencies and the culture of safety. West J Emerg Med 2015;16:810.CrossrefGoogle Scholar

  • 21.

    Katz D, Detsky AS. Incorporating metacognition into morbidity and mortality rounds: the next frontier in quality improvement. J Hosp Med 2016;11:120–2.PubMedCrossrefGoogle Scholar

  • 22.

    Campbell SG, Croskerry P, Bond WF. Profiles in patient safety: a “perfect storm” in the emergency department. Acad Emerg Med 2007;14:743–9.Google Scholar

  • 23.

    Rescher N. Predicting the future: an introduction to the theory of forecasting. Albany, NY: SUNY Press; 1998.Google Scholar

  • 24.

    Humphrey-Murto S, Varpio L, Gonsalves C, Wood TJ. Using consensus group methods such as Delphi and Nominal Group in medical education research. Med Teach 2017;39:14–9.CrossrefPubMedGoogle Scholar

  • 25.

    De Villiers MR, De Villiers PJ, Kent AP. The Delphi technique in health sciences education research. Med Teacher 2005; 27:639–43.CrossrefGoogle Scholar

  • 26.

    Holey EA, Feeley JL, Dixon J, Whittaker VJ. An exploration of the use of simple statistics to measure consensus and stability in Delphi studies. BMC Med Res Methodol 2007;7:52.CrossrefPubMedGoogle Scholar

  • 27.

    Yousuf MI. The Delphi technique. Essays in Education 2007;20:80–9.Google Scholar

  • 28.

    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–74.PubMedCrossrefGoogle Scholar

  • 29.

    Powers DM, editor The problem with kappa. Proceedings of the 13th Conference of the European Chapter of the Association for Computational Linguistics. Avignon, France: Association for Computational Linguistics, 2012.Google Scholar

  • 30.

    Astion ML, Shojania KG, Hamill TR, Kim S, Ng VL. Classifying laboratory incident reports to identify problems that jeopardize patient safety. Am J Clin Pathol 2003;120:18–26.PubMedCrossrefGoogle Scholar

  • 31.

    Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med 2002;9:1184–204.CrossrefPubMedGoogle Scholar

  • 32.

    Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. Br Med J Qual Saf 2015;24:103–10.CrossrefGoogle Scholar

  • 33.

    Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking. Acad Med 2017;92:23–30.CrossrefPubMedGoogle Scholar

  • 34.

    Zwaan L, Monteiro S, Sherbino J, Ilgen J, Howey B, Norman G. Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. Br Med J Qual Saf 2017;26:104–10.CrossrefGoogle Scholar

  • 35.

    Szostek JH, Wieland ML, Loertscher LL, Nelson DR, Wittich CM, McDonald FS, et al. A systems approach to morbidity and mortality conference. Am J Med 2010;123:663–8.CrossrefPubMedGoogle Scholar

  • 36.

    Deshpande JK, Throop PG, Slayton JM. Standardization of case reviews (morbidity and mortality rounds) promotes patient safety. Pediat Clin North Am 2012;59:1307–15.CrossrefGoogle Scholar

  • 37.

    Kahneman D. Thinking, fast and slow. New York: Farrar, Straus and Giroux, 2013.Google Scholar

  • 38.

    Norman G. Dual processing and diagnostic errors. Adv Health Sci Edu 2009;14:37–49.CrossrefGoogle Scholar

  • 39.

    Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases. Science 1974;185:1124–31.CrossrefPubMedGoogle Scholar

  • 40.

    Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Edu 2009;14:27–35.CrossrefGoogle Scholar

  • 41.

    Goldstein DG, Gigerenzer G. Models of ecological rationality: the recognition heuristic. Psychol Rev 2002;109:75.PubMedCrossrefGoogle Scholar

  • 42.

    Groopman JE, Prichard M. How doctors think: Houghton Mifflin Boston; 2007.Google Scholar

  • 43.

    Satish U, Streufert S. Value of a cognitive simulation in medicine: towards optimizing decision making performance of healthcare personnel. Br Med J Qual Saf 2002;11:163–7.Google Scholar

  • 44.

    Bond WF, Deitrick LM, Arnold DC, Kostenbader M, Barr GC, Kimmel SR, et al. Using simulation to instruct emergency medicine residents in cognitive forcing strategies. Acad Med 2004;79:438–46.CrossrefPubMedGoogle Scholar

  • 45.

    Daniel M, Carney M, Khandelwal S. Cognitive debiasing strategies: a faculty development workshop for clinical teachers in emergency medicine. MedEdPORTAL 2017;13:10646.Google Scholar

  • 46.

    Graber ML, Kissam S, Payne VL, Meyer AN, Sorensen A, Lenfestey N, et al. Cognitive interventions to reduce diagnostic error: a narrative review. Br Med J Qual Saf 2012;21:535–57.CrossrefGoogle Scholar

  • 47.

    Mehdi A, Foshee C, Green W, Spencer A. Cognitive autopsy: a transformative group approach to mitigate cognitive bias. J Grad Med Edu 2018;10:345–7.CrossrefGoogle Scholar

  • 48.

    Croskerry P. A universal model of diagnostic reasoning. Acad Med 2009;84:1022–8.CrossrefPubMedGoogle Scholar

  • 49.

    Epley N. Mindwise: why we misunderstand what others think, believe, feel, and want. New York City: Vintage, 2015.Google Scholar

  • 50.

    Sherbino J, Dore KL, Siu E, Norman GR. The effectiveness of cognitive forcing strategies to decrease diagnostic error: an exploratory study. Teach Learn Med 2011;23:78–84.PubMedCrossrefGoogle Scholar

  • 51.

    Reilly JB, Ogdie AR, Von Feldt JM, Myers JS. Teaching about how doctors think: a longitudinal curriculum in cognitive bias and diagnostic error for residents. Br Med J Qual Saf. 2013;22:1044–50.CrossrefGoogle Scholar

  • 52.

    Elstein AS. Thinking about diagnostic thinking: a 30-year perspective. Adv Health Sci Edu 2009;14:7–18.CrossrefGoogle Scholar

  • 53.

    Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9.CrossrefGoogle Scholar

  • 54.

    Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med 2013;368:246–53.PubMedCrossrefGoogle Scholar

  • 55.

    Shimizu T, Matsumoto K, Tokuda Y. Effects of the use of differential diagnosis checklist and general de-biasing checklist on diagnostic performance in comparison to intuitive diagnosis. Med Teach 2013;35:e1218–29.CrossrefPubMedGoogle Scholar

  • 56.

    Blumenthal-Barby JS, Krieger H. Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy. Med Dec Making 2015;35:539–57.CrossrefGoogle Scholar

  • 57.

    Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med 2003;41:110–20.PubMedCrossrefGoogle Scholar

  • 58.

    Kravet SJ, Howell E, Wright SM. Morbidity and mortality conference, grand rounds, and the ACGME’s core competencies. J Gen Intern Med 2006;21:1192–4.PubMedCrossrefGoogle Scholar

About the article

Corresponding author: Quentin Eichbaum, MD PhD MPH MFA MMHC, Professor of Pathology, Microbiology and Immunology, Professor of Medical Education and Administration, Vanderbilt Pathology Education Research Group (VPERG), Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), TVC 4511C, 1301 Medical Center Drive, Nashville, TN 37232-5310, USA, Phone: +(615)-936-5124, 617-697-9556 (mobile), E-mail: qeichbaum@gmail.com

Received: 2018-09-09

Accepted: 2018-10-30

Published Online: 2018-12-04

Published in Print: 2019-08-27

Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: None declared.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

Citation Information: Diagnosis, Volume 6, Issue 3, Pages 249–257, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2018-0089.

Export Citation

©2019 Walter de Gruyter GmbH, Berlin/Boston.Get Permission

Comments (0)

Please log in or register to comment.
Log in