Evidence and research
The Australian and international evidence on diagnostic error and clinical reasoning that the MEKSI framework is built on, the research behind it, and the published papers.
Published outcomes from MEKSI pilots and student evaluations.
Post-event report on the MEKSI OSCE competition run with University of Melbourne medical students: participation, scoring breakdown by domain, and the final leaderboard.
Download PDFAnonymised survey analysis of MEKSI's AI virtual-patient OSCE practice platform, prepared for discussion with AMSA medical education stakeholders.
Download PDFDiagnostic Error: Incidence, Impacts, Causes and Preventive Strategies (2020)
Evidence summary
Scott explains that diagnostic errors are common, preventable, and often result from failures in clinical reasoning rather than a lack of medical knowledge. The paper highlights cognitive biases, premature closure, and flawed information processing as major contributors to diagnostic error. It recommends improving diagnostic reasoning through metacognition, reflective practice, diagnostic checklists, cognitive forcing strategies, and education about cognitive bias to improve patient safety.
How this informed MEKSI
An Organisational Approach to Improving Diagnostic Safety (2023)
Evidence summary
Scott and Crock argue that diagnostic errors affect up to 10% of clinical encounters and contribute significantly to preventable patient harm. While cognitive failures are a major cause, healthcare organisations also play an important role in improving diagnostic safety. They propose an Australian framework that combines cognitive improvement with organisational strategies such as education, teamwork, communication, and systems designed to support better diagnostic reasoning.
How this informed MEKSI
Evidence summary
The Commission promotes improving diagnostic quality as part of safer healthcare. Its guidance emphasises accurate and timely diagnosis, effective communication, patient engagement, teamwork, and continuous quality improvement. Diagnostic excellence requires clinicians to use structured reasoning within systems that support safe decision-making.
How this informed MEKSI
Evidence summary
The Commission identifies diagnostic error as an important patient safety issue arising from both cognitive and system factors. It recommends learning from diagnostic errors, encouraging reflective practice, improving communication, and implementing practical strategies that strengthen diagnostic processes and reduce avoidable harm.
How this informed MEKSI
Collectively, Australian research consistently demonstrates that improving clinical reasoning, reducing cognitive bias, encouraging reflective practice, and supporting structured diagnostic processes are key strategies for reducing diagnostic error. These recurring themes form the evidence base from which the MEKSI framework has been developed.
Evidence summary
Croskerry's work demonstrates that many diagnostic errors arise from cognitive bias rather than insufficient medical knowledge. He explains that clinical reasoning involves both intuitive (fast) and analytical (slow) thinking, and that over-reliance on intuition can lead to diagnostic error. He recommends metacognition, reflective practice, cognitive forcing strategies, and structured reasoning to improve diagnostic accuracy and reduce cognitive bias.
How this informed MEKSI
Evidence summary
Graber identifies diagnostic error as one of the most significant threats to patient safety. His research concludes that cognitive failures account for a large proportion of diagnostic errors and argues that improving diagnostic reasoning, using structured diagnostic checklists, and encouraging reflective thinking can reduce these errors. He also promotes learning from diagnostic mistakes to strengthen future clinical decision-making.
How this informed MEKSI
Evidence summary
Singh's work emphasises that improving diagnosis requires attention to both clinician reasoning and healthcare systems. He defines diagnostic errors as missed opportunities in diagnosis and advocates improving the diagnostic process through better clinical reasoning, communication, teamwork, and systematic evaluation of diagnostic performance.
How this informed MEKSI
Evidence summary
Groopman explores how clinicians think during diagnosis and demonstrates that cognitive shortcuts frequently contribute to diagnostic error. He argues that clinicians should deliberately question their initial assumptions, consider alternative explanations, and avoid premature closure. His work highlights the importance of reflective clinical reasoning as a means of improving diagnostic accuracy.
How this informed MEKSI
Evidence summary
The landmark report Improving Diagnosis in Health Care concludes that diagnostic excellence depends on accurate clinical reasoning, effective communication, patient involvement, teamwork, and continuous learning. The report emphasises improving the entire diagnostic process rather than focusing solely on individual errors and recognises clinical reasoning as a central component of diagnostic quality.
How this informed MEKSI
Collectively, international research consistently demonstrates that improving clinical reasoning is one of the most effective strategies for reducing diagnostic error. Across multiple countries and healthcare systems, researchers identify common themes including structured reasoning, metacognition, reflective practice, cognitive debiasing, diagnostic checklists, and deliberate evaluation of alternative diagnoses. These evidence-based principles form the international foundation upon which the MEKSI framework has been developed.
Diagnostic Error: Incidence, Impacts, Causes and Preventive Strategies
Research summary
Scott and Crock conducted a comprehensive review of the medical literature to examine the frequency of diagnostic errors, their impact on patients, the cognitive and system-related causes of these errors, and strategies for prevention. The paper synthesised evidence from previous studies rather than collecting new experimental data, providing an overview of current knowledge on diagnostic error and diagnostic reasoning.
An Organisational Approach to Improving Diagnostic Safety
Research summary
This perspective paper reviewed contemporary evidence on diagnostic safety and proposed an organisational framework for improving diagnosis within Australian healthcare. The authors examined published research relating to clinician cognition, organisational systems, communication, education, governance, and patient safety to develop recommendations for reducing diagnostic error.
Research summary
The Commission undertakes systematic reviews of national and international evidence and develops evidence-based clinical standards, guidance documents, and policy recommendations. Its work examines how improvements in clinical reasoning, communication, teamwork, patient engagement, and healthcare systems contribute to safer diagnosis and improved patient outcomes.
Research summary
The Clinical Excellence Commission analyses diagnostic safety incidents, patient safety reports, and published literature to identify recurring causes of diagnostic error within Australian healthcare. Their work focuses on translating research evidence into practical recommendations that improve diagnostic processes and reduce preventable harm.
Research summary
Croskerry's research explores the psychology of clinical reasoning and diagnostic decision-making. His work draws on cognitive psychology, behavioural science, emergency medicine, and medical education to investigate why clinicians make diagnostic errors and how structured cognitive strategies can improve diagnostic accuracy.
Research summary
Graber's research investigates the epidemiology, causes, and prevention of diagnostic error. Through systematic reviews, expert consensus, and patient safety research, he examines how cognitive failures contribute to missed or delayed diagnoses and evaluates interventions designed to improve diagnostic reasoning.
Research summary
Singh's research focuses on diagnostic safety within healthcare systems. Using observational studies, patient safety research, health services research, and quality improvement methodologies, he investigates diagnostic processes and identifies opportunities to improve diagnostic performance through better clinical reasoning, communication, and system design.
Research summary
Groopman's work examines how physicians think during diagnosis. Drawing on clinical experience, interviews with clinicians, and cognitive science, his research explores how intuitive thinking, cognitive shortcuts, and reflective reasoning influence diagnostic accuracy.
Research summary
The National Academy of Medicine convened an expert committee to review thousands of studies on diagnostic error. The resulting report, Improving Diagnosis in Health Care, synthesised the available evidence to identify the causes of diagnostic error and develop recommendations for improving diagnostic quality across healthcare systems.