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

Block 1 Definition

Deaths annually because of Medical Error

An error is an action which is inaccurate or incorrect.

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

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

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

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

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

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

Block 2 Information Processing

Visual Error

Block 3 Action Theory & Errors

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.

Incorrect establishing the goal

Comatose Patient

establishing the goal In comatose patient Dx instead of Mx

Incorrect translation from goals to intentions

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

Incorrect action specifications from intentions

Instead of Bedside glucometry, order EEG

Incorrect execution of actions

Order Dw 5% instead of Hypertonic Glucose 50%

Misperception of system state

Misinterpretation of data perceived

Do not know the response of comatose patient because of hypoglycemia

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

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

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

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

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

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

(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?’’)

(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.

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

Block 4 Mistake vs. Slip

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

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

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

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

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)

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.

Execution slips

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

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

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

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

Evaluation Slips

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

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

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

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

Mistakes

Execution mistakes

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

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

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

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

Evaluation mistakes

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

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

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

Block 4 Debiasing

Perception Triggering Diagnosis= interpretation Correction

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

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

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

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

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

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

Medical Error Classification based on interpertation Medical Error SimpleKnowledgeProceduralComplexKnowledgeProcedural

Some Major Cognitive Errors