2. Cognitive Errors in Medicine Alireza Monajemi, MD-PhD Philosophy of Science & Technology Department IHCS

3. Block 1 Definition

4. 100.000 Deaths annually because of Medical Error

6. An error is an action which is inaccurate or incorrect.

7. Cognitive Bias = Error A cognitive bias is a pattern of poor judgment, often triggered by a particular situation.

8. Cognitive Bias = Error The existence of most of the particular cognitive biases has been verified in psychology experiments.

9. Why they exist Cognitive biases are influenced by evolution and natural selection pressure.

10. Why they exist General fault in human cognition structure Misapplication of a mechanism that is beneficial under different circumstances.

11. Why they exist adaptive and beneficial actions lead to more effective actions enable faster decisions for success and survival.

12. Areas where Cognitive biases occur Decision-making and behavioural biases Biases in probability and belief. Social biases Memory errors and biases

13. Block 2 Information Processing

18. Visual Error

22. Block 3 Action Theory & Errors

23. This taxonomy can cover major types of human errors, because a human error is an error in an action and any action goes through the seven stages of the action cycle.

25. Incorrect establishing the goal

26. Comatose Patient

27. establishing the goal In comatose patient Dx instead of Mx

28. Incorrect translation from goals to intentions

29. Example Know the priority of Mx in a comatose patient but plan a Dx procedure to Mx

30. Incorrect action specifications from intentions

31. Instead of Bedside glucometry, order EEG

32. Incorrect execution of actions

33. Order Dw 5% instead of Hypertonic Glucose 50%

34. Misperception of system state

35. Misinterpretation of data perceived

36. Do not know the response of comatose patient because of hypoglycemia

37. Misevaluation of interpreted information with regard to the goal of the task

38. Do not know how and when terminate the Mx plan of the patient

39. (2) forming the intention (e.g., ‘‘use keypad to enter 1000’’), which is concrete and dependent on the actual system or concrete setting

40. (3) specifying the action specification (e.g., ‘‘press 1 0 0 0’’), which is the formation of the sequence of actions to be carried out

41. ( 4) executing the action (e.g., ‘‘physically pressing 1 0 0 0’’), which is physically carrying out the actions

42. (5) perceiving the system state (e.g., ‘‘volume: 1000 cc, with 1000 highlighted’’), which is to detect and recognize any changes in system state

43. (6) interpreting the state, which means to make sense of the information perceived from the perception stage (e.g., ‘‘1000 cc is displayed, but what does the highlighting mean? Has the pump accepted the value, or must I press another button?’’)

44. (7) evaluating the system state with respect to the goals and intentions (e.g., ‘‘determine if the system has accepted the volume, i.e., press key to start infusion’’), which is to check if the original goal has been completed.

46. Near Miss A near miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so

47. Block 4 Mistake vs. Slip

48. Slip vs. Mistake Slip is an incorrect execution of a correct action sequence Mistake is the correct execution of an incorrect action sequence

49. Mistakes occurs When behavior leads to a failure because of incorrect or incomplete knowledge

50. Slip occurs When the knowledge is correct, but a failure occurs

51. Slip misinterpreting feedback because of expectations (e.g., reading 1301 as the expected 130.1)

52. Mistake misinterpreting feedback because of incorrectly acquired or missing knowledge (e.g., thinking that a blinking red light means the device is working, when in reality it means the battery is low)

53. Example of Slip we all know the difference between a computer mouse and a cell phone, but if a mouse and cell phone are next to each other on our desks, we may accidentally pick up the mouse when the phone rings or we may accidentally reach for the phone when we want to move the mouse—both examples of a slip.

55. Execution slips

56. Goal slips Cognitive mechanisms Loss of activation Altered goal Overflow of working memory Potential solutions Provide memory aids Reduce multitasking Reduce interruptions Reduce goal overload

57. Intention slips Cognitive mechanisms Loss of activation Altered intention Overflow of working memory Potential solutions Reduce interruptions Situated actions Reduce multitasking Provide memory aids

58. Action specification slips Cognitive mechanisms Associative activation Failure of retrieval Potential solutions Automation Decision support Direct action

59. Action execution slips Cognitive mechanisms Perceptual confusion Deviation of motor skills Potential solutions Display design Automation Visualization Reduce interruption

60. Evaluation Slips

61. Perception Slips Cognitive mechanisms Lack of perception Misperception Mis-anticipation Potential solutions Direct perception Immediate feedback

62. Interpretation Slips Cognitive mechanisms Default knowledge Confirmation bias Information overload Potential solutions Display design Decision support User training Memory aids Situation awareness

63. Action evaluation slips Cognitive mechanisms Lost memory of goal Lack of feedback Insufficient information Ambiguous information Evaluating different goal Potential solutions Memory aids Display design Action tracking Information reduction

64. Action evaluation slips Cognitive mechanisms Lost memory of goal Lack of feedback Insufficient information Ambiguous information Evaluating different goal Potential solutions Memory aids Display design Action tracking Information reduction

65. Mistakes

66. Execution mistakes

67. Goal Mistakes Cognitive mechanisms Incorrect knowledge Incomplete knowledge Misuse of knowledge Biases & faulty heuristics Information overload Potential solutions Education Decision support Representational aid

69. Intention mistakes Cognitive mechanisms Incorrect knowledge Incomplete knowledge Misuse of knowledge Biases & faulty heuristics Information overload Potential solutions Education Decision support Representational aid

70. Action specification mistakes Cognitive mechanisms Lack of correct rules Encoding deficiencies in rules Potential solutions Education Decision support Representational aid

72. Action execution mistakes Cognitive mechanisms Misapplication of good rules Dissociation between knowledge and rules Potential solutions Education Representational aid

73. Evaluation mistakes

74. Perception Mistakes Cognitive mechanisms Lack of perception Misperception Mis-anticipation Potential solutions Aids for perceptual systems Display design

75. Interpretation Mistakes Cognitive mechanisms Incorrect knowledge Incomplete knowledge Information overload Potential solutions Education Representational aid Information reduction Display design

76. Action Evaluation Mistakes Cognitive mechanisms Incorrect knowledge Incomplete knowledge Information overload Potential solutions Education Representational aid Information reduction Display design

77. Block 4 Debiasing

78. Perception Triggering Diagnosis= interpretation Correction

79. Error perception is a critical step in the cycle, since without it the error will not be noticed.

80. Error perception expert ability to recognize the pattern underlying multiple subtle cues expectancies based on the ability to recognize chains of events using a causal framework expert mental models (including models of the instruments used to collect observed data) a sense of typicality, which provides a baseline for the detection of anomalies

81. process of error detection=triggering spontaneous (in response to some perceived discrepancy) systematic (for example, the use of a checklist to prevent procedural errors

82. Error Detection occurs when “the problem solver perceives a discrepancy between the results produced and his expectations

83. one is applying knowledge of the domain in order to anticipate the outcome of executed actions

85. I. Simple errors: Errors that require single step inference along II. Complex errors: Errors that require integration of multiple data elements III. Knowledge-based errors: Errors caused by incorrect or incomplete medical knowledge IV. Procedural errors: Errors caused by deviations from standard task-oriented clinical guidelines and procedures

86. Medical Error Classification based on interpertation Medical Error SimpleKnowledgeProceduralComplexKnowledgeProcedural

92. Some Major Cognitive Errors