Intended for healthcare professionals

Feature Christmas 2016: In Love and War

War games and diagnostic errors

BMJ 2016; 355 doi: (Published 13 December 2016) Cite this as: BMJ 2016;355:i6342
  1. Valerie M Vaughn, clinical lecturer1,
  2. Vineet Chopra, assistant professor of medicine1,
  3. Joel D Howell, Victor Vaughan professor of the history of medicine2
  1. 1Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
  2. 2Departments of Internal Medicine, History, and Health Management and Policy, University of Michigan
  1. Correspondence to: valmv{at}

Could lessons from the cold war help reduce diagnostic error, ask Valerie Vaughn and colleagues

From the 1940s to the 1990s the United States and the former Soviet Union (USSR) confronted each other in a cold war. Each side feared and distrusted the other. Each side was prepared to respond to an attack with immediate nuclear retaliation. Although this stance of “mutually assured destruction” helped to avoid all-out war, the cold war threatened to turn hot on several occasions. Perhaps the most notable of these events occurred in the autumn of 1983, when the USSR mistakenly interpreted “Able Archer,” a routine military exercise from the North Atlantic Treaty Organisation, as cover for an impending first strike. The US compounded the error by failing to recognise Soviet fears and continuing military activities as planned, pushing Soviet leaders close to their own pre-emptive first strike attack and catastrophic nuclear war.

A report from the US President’s Foreign Intelligence Advisory Board, completed in 1990 but declassified in 2015, shows that the US had ample information to identify Soviet fears and pursue a calming course but failed to do so.1 Here we explore the parallels between this near catastrophe and medical diagnostic errors. We look at how the mistakes made by the US were due to cognitive bias rather than inaccurate data and how lessons learnt from Able Archer may inform efforts to reduce diagnostic error in medicine.

Similarities between intelligence analysts and doctors

Both intelligence analysis and medical practitioners must make sense of information using human perception, cognition, theory, and emotional and social intelligence to construct a coherent account of the world.2 Both groups use data that are sometimes clear, frequently shifting, often contradictory, and always incomplete to inform many decisions made quickly in a dynamic environment—all with the expectation of solving a problem that may be …

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