Each year, approximately 141 million emergency department (ED) visits occur in the United States. The decision making needed to make a diagnosis for a patient who presents to the ED occurs in a time- and information-constrained environment.1-3 Therefore, the ED creates a high-risk environment where physicians and nurses are particularly susceptible to making a diagnostic error.
The inherent uncertainty of the diagnostic process makes it highly susceptible to errors.4 The National Academies of Sciences, Engineering, and Medicine (NASEM) defines diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.”5 Even a conservative estimate of diagnostic error occurring in 5 percent of ED visits translates to about 7 million cases of ED-based diagnostic error per year, with nearly half having the potential for patient harm.6
Diagnosis occurs as a collective exchange of facts, findings, and strategies within a defined structure (e.g., presentation of the patient who arrives in the ED) and hierarchy (e.g., nurse or physician). In this view, diagnosis is not the result of solitary thinking but rather a process that occurs through interactions with others who contribute their own unique perceptions and conclusions in a world that is “thick with artifacts.”7
Known as distributed cognition,8 this view of the diagnostic process is especially salient because various involved parties (patients/family members, nurses, physicians, other clinicians) have different knowledge by virtue of their experiences, disciplinary training, or physical location in time and space. Since no single individual can grasp everything,9 distributed cognition allows involved parties to share understanding of goals, plans, and details from all sources to arrive at a diagnosis.
Traditionally, the diagnostic process has been viewed as an individual cognitive activity of information processing, usually performed by physicians.10,11 This view does not capitalize on the wisdom of other members of the ED diagnostic team, such as nurses, consultants, and trainees. These individuals have unique, valuable knowledge that should be considered when making diagnoses in the ED.
Departing from the traditional view of diagnosis as an individual effort, diagnosis should be viewed as a team effort, with an integral and consistent part being nursing involvement.12,13 Nurses’ input can be critical because nursing knowledge complements yet is different from medical knowledge and is based not only on principles of science but also on holism and intuition.14,15 Patients and family members are another crucial group whose input is essential to optimize diagnosis.
This issue brief discusses the nurse’s role in diagnostic safety, using the conceptual lens of distributed cognition. We begin by describing the theory of distributed cognition, move on to discuss the nurse’s role in diagnosis through that conceptual lens, and conclude with some suggestions for future areas of practice and research.
