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1

Blanche, Tony. Death in paradise: An illustrated history of the Los Angeles County Department of Coroner. Los Angeles: General Pub. Group, 1998.

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2

Blanche, Tony. Death in paradise: An illustrated history of the Los Angeles County Department of Coroner. Los Angeles: General Pub. Group, 1998.

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3

Colin, Evans. Blood on the table: The greatest cases of New York City's Office of the Chief Medical Examiner. Waterville, Me: Thorndike Press, 2008.

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4

Francisco), California Grand Jury (San. San Francisco Police Department/Crime Laboratory (SFPD/CL) and San Francisco Medical Examiner/Toxicology Laboratory (SFME/TL). [San Francisco, Calif: Grand Jury, 1996.

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5

Center, DC Appleseed. Problems at the District of Columbia's Office of The Chief Medical Examiner: A recommendation for structural reform : DC Appleseed Center report. Washington, DC: DC Appleseed Center, 1998.

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6

Ribowsky, Shiya. Dead center: Behind the scenes at the world's largest medical examiner's office. New York: Regan, 2006.

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7

Great Britain. Department of Health. Chief Medical Officer. On the state of the public health: The annual report of the Chief Medical Officer of the Department of Health. London: HMSO, 1990.

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8

On the state of the public health: The annual report of the Chief Medical Officer of the Department of Health. London: HMSO, 1994.

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9

Great Britain. Department of Health. Chief Medical Officer. On the state of the public health: The annual report of the Chief Medical Officer of the Department of Health. London: HMSO, 1996.

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10

Great Britain. Department of Health. Chief Medical Officer. On the state of the public health: The annual report of the Chief Medical Officer of the Department of Health. London: HMSO, 1993.

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11

Great Britain. Department of Health. Chief Medical Officer. On the state of the public health: The annual report of the Chief Medical Officer of the Department of Health. London: Department of Health, 2004.

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12

Shachtman, Tom. Dead Center. New York: HarperCollins, 2006.

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13

Health in Scotland: Report by the Chief Medical Officer of the Scottish Home and Health Department to the Secretary of State for Scotland. Edinburgh: H.M.S.O., 1989.

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14

Officer, Great Britain Department of Health and Social Security Chief Medical. On the state of the public health: The annual report of the Chief Medical Officer of the Department of Health and Social Security. London: H.M.S.O., 1986.

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15

Clinical Resource and Audit Group. Health in Scotland: A report by the Chief Medical Officer of the Scottish Home and Health Department to the Secretary of State for Scotland. Edinburgh: HMSO, 1986.

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16

On the state of the public health: The annual report of the Chief Medical Officer of the Department of Health for the year 1997. London: Stationery Office, 1998.

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17

Great Britain. Department of Health. Chief Medical Officer. On the state of the public health: The annual report of the Chief Medical Officer of the Department of Health for the year 1996. London: Stationery Office, 1997.

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18

On the state of the public health: The annual report of the Chief medical officer of the Department of Health for the year 1988. London: H.M.S.O., 1989.

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19

Sub-Group, Great Britain Chief Medical Officer's Health of the Nation Working Group Variations. Variations in health: What can the Department of Health and the NHS do? : a report produced by the Variations Sub-Group of the Chief Medical Officer's Health of the Nation Working Group. [London]: Department of Health, 1995.

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20

Great Britain. Chief Medical Officer's Health of the Nation Working Group. Variations Sub-Group. Variations in health: What can the Department of Health and the NHS do? : a report produced by the Variations Sub-Group of the Chief Medical Officer's Health of the Nation Working Group. [London]: Department of Health, 1996.

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21

Great Britain. Department of Health. Chief Medical Officer. On the state of the public health for the year 1996: Introduction to the annual report of the Chief Medical Officer of the Department of Health to the Secretary of State for Health. London: Stationery Office, 1997.

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22

Nomination of Alexander G. Garza: Hearing before the Committee on Homeland Security and Governmental Affairs, United States Senate of the One Hundred Eleventh Congress, first session : nomination of Alexander G. Garza to be assistant secretary and chief medical officer, U.S. Department of Homeland Security, July 28, 2009. Washington: U.S. G.P.O., 2010.

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23

The Department of Homeland Security Second Stage Review: The role of the Chief Medical Officer : hearing before the Subcommittee on Management, Integration, and Oversight of the Committee on Homeland Security, House of Representatives, One Hundred Ninth Congress, first session, October 27, 2005. Washington: U.S. G.P.O., 2007.

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24

Affairs, United States Congress Senate Committee on Veterans'. Nominations of Dr. James W. Holsinger, Jr., and Stephen A. Trodden: Hearing before the Committee on Veterans' Affairs, United States Senate, One Hundred First Congress, second session, on the nomination of Dr. James W. Holsinger, Jr., to be Chief Medical Director, and Stephen A. Trodden, to be Inspector General, Department of Veterans Affairs, June 19, 1990. Washington: U.S. G.P.O., 1990.

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25

Affairs, United States Congress Senate Committee on Veterans'. Nominations of Dr. James W. Holsinger, Jr., and Stephen A. Trodden: Hearing before the Committee on Veterans' Affairs, United States Senate, One Hundred First Congress, second session, on the nominations of Dr. James W. Holsinger, Jr., to be Chief Medical Director, and Stephen A. Trodden, to be Inspector General, Department of Veterans Affairs, June 19, 1990. Washington: U.S. G.P.O., 1990.

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26

Schreiber, Brad, and Tony Blanche. Death in Paradise: An Illustrated History of the Los Angeles County Department of Coroner. Four Walls Eight Windows, 2001.

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27

Deputy Chief Medical Examiner. National Learning Corp, 1994.

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28

Rudman, Jack. Chief Medical Examiner (Career Examination Ser.; C-1180). National Learning Corp, 1991.

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29

Blood On The Table: The Greatest Cases of New York City's Office of the Chief Medical Examiner. Berkley Trade, 2008.

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30

1935-, Axelrod David, and New York (State). Dept. of Health, eds. Report to the governor on the Office of the Chief Medical Examiner of the City of New York. [Albany, N.Y.]: New York State Department of Health, 1985.

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31

Schulman, Nisson. Jewish Answers to Medical Questions: Questions and Answers from the Medical Ethics Department of Chief Rabbi of Great Britain. Jason Aronson, 1998.

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32

DRUG ABUSE WARNING NETWORK ANNUAL MEDICAL EXAMINER DATA 1998... DRUG ABUSE WARNING NETWORK SERIES: D-13... U.S. DEPARTMENT OF HEALTH & HUMAN. [S.l: s.n., 2000.

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33

United States. Substance Abuse and Mental Health Services Administration., ed. DRUG ABUSE WARNING NETWORK ANNUAL MEDICAL EXAMINER DATA 1997... DRUG ABUSE WARNING NETWORK SERIES: D-12... U.S. DEPARTMENT OF HEALTH & HUMAN. [S.l: s.n., 2000.

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34

Oregon. State Medical Examiner's Office. and Oregon Division of Audits, eds. Department of Human Resources, Health Division, Office of Medical Examiner, Portland, Oregon: Report on accountability for public funds, October 11, 1985. Salem, Or: The Division, 1985.

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35

Gottlieb, Terry Diane Walsh. TRANSACTIONAL AND TRANSFORMATIONAL LEADERSHIP SYTLES OF CHIEF AND ASSOCIATED CHIEF NURSES IN DEPARTMENT OF VETERANS' AFFAIRS MEDICAL CENTERS: A DESCRIPTIVE STUDY (VA HOSPITALS, CHIEF NURSES, NURSES, TRANSACTIONAL LEADERSHIP, LEADERSHIP). 1990.

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36

Ribowsky, Shiya, and Tom Shachtman. Dead Center: Behind the Scenes at the World's Largest Medical Examiner's Office. Harper Paperbacks, 2007.

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37

Ribowsky, Shiya, and Tom Shachtman. Dead Center: Behind the Scenes at the World's Largest Medical Examiner's Office. William Morrow, 2006.

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38

Ribowsky, Shiya, and Tom Shachtman. Dead Center: Behind the Scenes at the World's Largest Medical Examiner's Office. Harper Paperbacks, 2007.

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39

Ribowsky, Shiya, and Tom Shachtman. Dead Center: Behind the Scenes at the World's Largest Medical Examiner's Office. William Morrow, 2006.

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40

Great Britain. Department of Health and Social Security. Chief Medical Officer., ed. On the state of the public health: The annual report of the Chief Medical Officer of the Department of Health and Social Security. London: H.M.S.O., 1986.

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41

Britain, Great. Health in Scotland 1991: A Report by the Chief Medical Officer of the Scottish Office Home and Health Department to the Secretary of State for. HMSO Books, 1992.

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42

United States. Congress. House. Select Committee on Homeland Security., ed. The Department of Homeland Security Second Stage Review: The Role of the Chief Medical Officer, Serial No. 109-51, October 27, 2005, 109-1 Hearing, *. [S.l: s.n., 2008.

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43

On the State of the Public Health: The Annual Report of the Chief Medical Officer of the Department of Health and Social Security for the Year 1987. Her Majesty's Stationery Office, 1988.

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44

F, Oliver M., Wood David, Ashley-Miller Michael, University of Edinburgh. Cardiovascular Research Unit., and Great Britain. Scottish Home and Health Department. Chief Scientist Office., eds. Screening for risk of coronary heart disease: Proceedings of a workshop on strategies for screening for risk of coronary heart disease organised jointly by the CardiovascularResearch Unit, Edinburgh University and the Chief Scientist Office, Scottish Home and Health Department and held at the King Khalid Conference Centre, Royal College of Surgeons, Edinburgh on 14 and 15 November 1985. Chichester: Wiley, 1987.

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45

F, Oliver M., Ashley-Miller Michael, Wood David, University of Edinburgh. Cardiovascular Research Unit., and Great Britain. Chief Scientist Office., eds. Screening for risk of coronary heart disease: Proceedings of a workshop on strategies for screening for risk of coronary heart disease organised jointly by the Cardiovascular Research Unit, Edinburgh University and the Chief Scientist Office, Scottish Home and Health Department and held at the King Khalid Conference Centre, Royal College of Surgeons, Edinburgh on 14 and 15 November 1985. Chichester: Wiley, 1987.

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46

Croskerry, Pat. The Cognitive Autopsy. Oxford University Press, 2020. http://dx.doi.org/10.1093/med/9780190088743.001.0001.

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Behind heart disease and cancer, medical error is now listed as one of the leading causes of death. Of the medical errors that lead to injury and death, diagnostic failure is regarded as the most significant. Generally, the majority of diagnostic failures are attributed to the clinicians directly involved with the patient, and to a lesser extent, the system in which they work. In turn, the majority of errors made by clinicians is due to decision making failures manifested by various departures from rationality. Of all the medical environments in which patients are seen and diagnosed, the emergency department is the most challenging. It has been described as a ‘wicked’ environment where illness and disease may range from minor ailments and complaints to severe, life-threatening disorders. The Cognitive Autopsy is a novel strategy towards understanding medical error and diagnostic failure in 42 clinical cases with which the author was directly involved or became aware of at the time. Essentially, it describes a cognitive approach towards root cause analysis of medical adverse events or near misses. Whereas root cause analysis typically focuses on the observable and measurable aspects of adverse events, the cognitive autopsy attempts to identify covert cognitive processes that may have contributed to outcomes. In this clinical setting, no cognitive process is directly observable but must be inferred from the behaviour of the individual clinician. The book illustrates unequivocally that chief among these cognitive processes are cognitive biases and other flaws in decision making, rather than knowledge deficits.
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