Patient Safety CME Curriculum Patient Safety: The Other Side of the Quality Equation

1. Patient Safety CME CurriculumPatient Safety: The Other Side of the Quality Equation Under a Grant from The Agency for Healthcare Research and Quality Principal Investigator Christel Mottur-Pilson, PhD Director, Scientific Policy ACP-ASIM

2. Patient Safety: The Other Side of the Quality EquationSeven Modules in Ambulatory Care Systems The influence of systems on the practice of medicine. Cognitive Capacity Coping mechanisms under information overload and time pressures Communication Communication barriers, lack, and unclear communication Medication Errors Uniform dosing, look- and sound-alikes, forcing functions A brief overview The following 2 slides identify seven modules reflecting different perspectives of the overall systems approach to patient safety. While a certain amount of overlap is taken to be understood between the modules because of the systems approach, the present module- cognition- sheds light on challenges of decision making at all levels of health care. And as we now know, any disruption in the system affects the quality of health care provided to patients. The choice of these modules is not arbitrary but is based on the ground breaking Institute of Medicine report, To Err Is Human, published November 1999. This report, more than any other publication, highlighted patient safety problems and captured the attention of the public and the medical profession. A brief overview The following 2 slides identify seven modules reflecting different perspectives of the overall systems approach to patient safety. While a certain amount of overlap is taken to be understood between the modules because of the systems approach, the present module- cognition- sheds light on challenges of decision making at all levels of health care. And as we now know, any disruption in the system affects the quality of health care provided to patients. The choice of these modules is not arbitrary but is based on the ground breaking Institute of Medicine report, To Err Is Human, published November 1999. This report, more than any other publication, highlighted patient safety problems and captured the attention of the public and the medical profession.

3. Patient Safety: The Other Side of the Quality EquationSeven Modules in Ambulatory Care The Role of Patients Patients as allies in patient safety The Role of Electronics Supportive products and processes Idealized Office Design Medical practice design to support patient safety Before discussing the role of cognition in patient safety, let us first provide several logistics for obtaining CME credit for this presentation.Before discussing the role of cognition in patient safety, let us first provide several logistics for obtaining CME credit for this presentation.

4. Logistics CME: To receive your CME, please fill out the usual forms Evaluation form CME form Research Grant Surveys Pre-CME assessment of knowledge level Post-CME assessment of knowledge level Six-month follow up to CME Virtual Patient Safety Electronic Community There are three components of the research effort that you are involved in. � Component One refers to your usual CME evaluation that helps the College keep track of the quality of its CME offering. If your particular Chapter receives its CME from another accredited source, they will probably have a similar form of their own. � In addition, there is the College CME form which you need to fill out to receive your CME credit. � Component Two refers to the research questionnaires which will help us determine the staying power of the CME content. � Survey 1 To be filled out before attending the session provides an assessment of your knowledge base on this subject before the lecture. It provides a baseline for future comparisons with survey 2 and survey 3. It is vitally important that you fill this out prior to the CME program. � Survey 2 This survey will focus on your knowledge and attitudes concerning the patient safety curriculum. Please do not neglect to fill this survey out. � Survey 3 Will be mailed six months after the meeting. Survey 3 measures physician behavior change as reported by the respondents. � Component Three is the virtual patient safety community. It will be electronically activated about a month after the CME session has taken place. The purpose of this activity is to share with your peers, electronically, how the take home points from the CME session work in practice, how they may need to be adapted to local circumstances or replaced with similar tools that actually work better. You will receive detailed instructions on how to activate your membership in the virtual patient safety community via letter and e-mail. � Enough of these preliminaries; let�s turn to a discussion of cognition in the context of patient safety. There are three components of the research effort that you are involved in. � Component One refers to your usual CME evaluation that helps the College keep track of the quality of its CME offering. If your particular Chapter receives its CME from another accredited source, they will probably have a similar form of their own. � In addition, there is the College CME form which you need to fill out to receive your CME credit. � Component Two refers to the research questionnaires which will help us determine the staying power of the CME content. � Survey 1 To be filled out before attending the session provides an assessment of your knowledge base on this subject before the lecture. It provides a baseline for future comparisons with survey 2 and survey 3. It is vitally important that you fill this out prior to the CME program. � Survey 2 This survey will focus on your knowledge and attitudes concerning the patient safety curriculum. Please do not neglect to fill this survey out. � Survey 3 Will be mailed six months after the meeting. Survey 3 measures physician behavior change as reported by the respondents. � Component Three is the virtual patient safety community. It will be electronically activated about a month after the CME session has taken place. The purpose of this activity is to share with your peers, electronically, how the take home points from the CME session work in practice, how they may need to be adapted to local circumstances or replaced with similar tools that actually work better. You will receive detailed instructions on how to activate your membership in the virtual patient safety community via letter and e-mail. � Enough of these preliminaries; let�s turn to a discussion of cognition in the context of patient safety.

5. Cognitive Capacity Influence of systems on cognitive capacity Information processing Human factors Relationship of these 3 factors to patient safety Medical decision making is shaped by two equally important factors, the innate capacity of human beings to process information and the context in which this occurs. We have limited control over both these factors, though they influence and shape many patient outcomes. To underscore the pervasive influence of systems on the entire field of patient safety, we shall highlight the relationship between systems and medical decision making. As a discipline, human information processing draws heavily on cognitive psychology. However, for the purpose of this module, we shall only select those key concepts that will help us understand the relationship between patient safety and cognition. At times you may hear references to �human factor� analysis. This is just another way of approaching cognitive capacity and problem solving. However, human factor analysis is always situated and influenced by complex systems embedded in the social environment. Since our focus is on the influence of systems, both terms can be used interchangeably. All three areas, cognitive capacity, information processing, and human factors are governed by our innate capacity to select, store and process stimuli. Finally, these three areas impact patient safety in a variety of ways. Medical decision making is shaped by two equally important factors, the innate capacity of human beings to process information and the context in which this occurs. We have limited control over both these factors, though they influence and shape many patient outcomes. To underscore the pervasive influence of systems on the entire field of patient safety, we shall highlight the relationship between systems and medical decision making. As a discipline, human information processing draws heavily on cognitive psychology. However, for the purpose of this module, we shall only select those key concepts that will help us understand the relationship between patient safety and cognition. At times you may hear references to �human factor� analysis. This is just another way of approaching cognitive capacity and problem solving. However, human factor analysis is always situated and influenced by complex systems embedded in the social environment. Since our focus is on the influence of systems, both terms can be used interchangeably. All three areas, cognitive capacity, information processing, and human factors are governed by our innate capacity to select, store and process stimuli. Finally, these three areas impact patient safety in a variety of ways.

6. Presentation Goals Understanding how cognition influences patient safety Awareness of the influence of cognition in a systems context via clinical cases Take home points to guard against cognitive lapses Understanding the fundamental influence of cognition on how we process information and arrive at medical decisions guards against looking for individual culpability. Coupling this understanding with our appreciation of how systems play key roles in outcomes, will assist physicians to avoid the name, blame and shame trap that human beings so easily fall into. Instead, awareness of the confluence of cognition and systems on patient safety fosters readiness to focus on the �blunt end� of medicine, such as institutional factors, rather than the �sharp end, � the actions of the physician. Cook and Woods (1) coined the phrase �blunt end� as an analogy to Reason�s �sharp end� (2). Briefly, the blunt end refers to the largely invisible constraints and rules physicians work under whereas the sharp end is the actual visible action. The work of these authors underscores how the blunt end can influence the sharp end. Individual clinical case scenarios will heighten awareness of cognition and how systems can effect cognition. Take home points will allow you to apply these new insights into your own office setting. Cook, RI and Woods, DD. 1994. Operating at the Sharp End: The Complexity of Human Error. Pp. 255-310. In Human Error in Medicine. Ed. Bogner, MS. Hillsdale, NJ.:Lawrence Earlbaum Associates. Reason, J. 1990. Human Error. Cambridge: Cambridge University Press. Understanding the fundamental influence of cognition on how we process information and arrive at medical decisions guards against looking for individual culpability. Coupling this understanding with our appreciation of how systems play key roles in outcomes, will assist physicians to avoid the name, blame and shame trap that human beings so easily fall into. Instead, awareness of the confluence of cognition and systems on patient safety fosters readiness to focus on the �blunt end� of medicine, such as institutional factors, rather than the �sharp end, � the actions of the physician. Cook and Woods (1) coined the phrase �blunt end� as an analogy to Reason�s �sharp end� (2). Briefly, the blunt end refers to the largely invisible constraints and rules physicians work under whereas the sharp end is the actual visible action. The work of these authors underscores how the blunt end can influence the sharp end. Individual clinical case scenarios will heighten awareness of cognition and how systems can effect cognition. Take home points will allow you to apply these new insights into your own office setting. Cook, RI and Woods, DD. 1994. Operating at the Sharp End: The Complexity of Human Error. Pp. 255-310. In Human Error in Medicine. Ed. Bogner, MS. Hillsdale, NJ.:Lawrence Earlbaum Associates. Reason, J. 1990. Human Error. Cambridge: Cambridge University Press.

7. Humans as Information Processing Systems Variables affecting information processing: Overall systems context Attention Perception Mindset If we accept the notion of human beings as information processing systems (1), we need to consider which variables can affect the performance of this process. Once we have focused on the most salient variables, we shall move to how these variables are processed and how they can affect medical decision making. Decision making here is seen in the broadest context, ranging from arriving at a differential diagnosis to reaching for a topical anesthesia agent. The role of each variable will be demonstrated separately. Nevertheless, an attempt will be made to link the various variables together and show their influence on each other. 1. Hollnagel, E. 1993. Human Reliability Analysis. Context and Control. London: Academic Press. If we accept the notion of human beings as information processing systems (1), we need to consider which variables can affect the performance of this process. Once we have focused on the most salient variables, we shall move to how these variables are processed and how they can affect medical decision making. Decision making here is seen in the broadest context, ranging from arriving at a differential diagnosis to reaching for a topical anesthesia agent. The role of each variable will be demonstrated separately. Nevertheless, an attempt will be made to link the various variables together and show their influence on each other. 1. Hollnagel, E. 1993. Human Reliability Analysis. Context and Control. London: Academic Press.

8. Systems Context System constraints Time pressure Conflicting goals Insurance companies System facilitators Discussion with colleagues Point of service decision aids Depending on how wide one is inclined to cast the net, system constraints can reach back to the socialization process in medical training or focus more narrowly on the here and now. Most of you probably labor under time pressures imposed by the requirement to see x number of patients a day to meet your fiscal needs or those of a provider you are associated with. It is a well known fact that time pressure adversely affects attention, perception and information processing. Under time pressure it is difficult to focus on the relevant detail necessary to extract the called-for diagnosis or pattern. System constraints frequently present the physician with conflicting goals. On the one hand, health plans attempt to preserve monetary resources by limiting drug choices to prescribed formularies, on the other hand health plans expect a simple office visit to only last 8 to 9 minutes. Since physicians deal with multiple insurance companies, it is impossible to know all the formularies by heart. Looking up the appropriate drug takes time away from the present visit or burdens the next visit. Since the capacity for attention is limited, the capacity to focus on the presenting problem is impaired by worrying about which formulary to use, or how to make up the lost time expended on the previous patient. Under these circumstances, the most pressing goal tends to be attended to, to the detriment of the other. In general, we acknowledge that increased workload tends to negatively impinge on performance. In contrast to the above scenario, systems can also positively influence decision making. For example, the ability to discuss a difficult case with colleagues benefits the physician and the patient. If the office has an electronic decision support tool, such as ePocrates, many dangerous drug interactions can be avoided. Or again, if the office has an electronic medical record linked to lab results, the results can be discussed with the patient face-to-face saving time for both physician and patient. Depending on how wide one is inclined to cast the net, system constraints can reach back to the socialization process in medical training or focus more narrowly on the here and now. Most of you probably labor under time pressures imposed by the requirement to see x number of patients a day to meet your fiscal needs or those of a provider you are associated with. It is a well known fact that time pressure adversely affects attention, perception and information processing. Under time pressure it is difficult to focus on the relevant detail necessary to extract the called-for diagnosis or pattern. System constraints frequently present the physician with conflicting goals. On the one hand, health plans attempt to preserve monetary resources by limiting drug choices to prescribed formularies, on the other hand health plans expect a simple office visit to only last 8 to 9 minutes. Since physicians deal with multiple insurance companies, it is impossible to know all the formularies by heart. Looking up the appropriate drug takes time away from the present visit or burdens the next visit. Since the capacity for attention is limited, the capacity to focus on the presenting problem is impaired by worrying about which formulary to use, or how to make up the lost time expended on the previous patient. Under these circumstances, the most pressing goal tends to be attended to, to the detriment of the other. In general, we acknowledge that increased workload tends to negatively impinge on performance. In contrast to the above scenario, systems can also positively influence decision making. For example, the ability to discuss a difficult case with colleagues benefits the physician and the patient. If the office has an electronic decision support tool, such as ePocrates, many dangerous drug interactions can be avoided. Or again, if the office has an electronic medical record linked to lab results, the results can be discussed with the patient face-to-face saving time for both physician and patient.

9. Attention Multiple theories of attention Common sense perception of attention Relationship between perception, mindset and attention There are multiple theories of attention. Some theorists insist on the limited nature of attention capacity. Others posit a more bountiful resource. Still others differentiate between the attention needs of complex and routine tasks. Whatever the case may be, common sense recognizes that individuals are highly unlikely to deal with two complex situations requiring simultaneous attention and effective action. Furthermore, common sense recognizes the ability to focus on a given task as a desirable talent. All of this speaks to the variable nature of attention spans. Selective attention is strongly influenced by our expectations or mindset. If, for example, a patient presents with the complaint of breathing difficulty as noted by the office appointment request, but also mentions pain in his/her leg, the physician may ignore the leg and focus exclusively on the breathing difficulty. In so doing the physician may fail to recognize the likely symptomatology of DVT/PE. Another side of selective attention comes to the fore when a problem is so pressing that the individual becomes fixated on solving this overriding concern to the detriment of the real solution. As Norman (1) has recounted, divers, struggling to reach the surface of the water, frequently forget to release the weights on their belts which helped them stay down. Similarly, focusing exclusively on keeping blood pressure low during cardiac surgery to avoid heart muscle strain, may miss the need for higher blood pressure to keep the heart muscle supplied with oxygen. As we have seen here the demands on attention are shifting and varied. Depending on previous experience, referred to as schemata by cognitive researchers, multiple stimuli are sorted into familiar patterns that help process them. 1. Norman, DA. 1988. The Psychology of Everyday Things. Basic Books. There are multiple theories of attention. Some theorists insist on the limited nature of attention capacity. Others posit a more bountiful resource. Still others differentiate between the attention needs of complex and routine tasks. Whatever the case may be, common sense recognizes that individuals are highly unlikely to deal with two complex situations requiring simultaneous attention and effective action. Furthermore, common sense recognizes the ability to focus on a given task as a desirable talent. All of this speaks to the variable nature of attention spans. Selective attention is strongly influenced by our expectations or mindset. If, for example, a patient presents with the complaint of breathing difficulty as noted by the office appointment request, but also mentions pain in his/her leg, the physician may ignore the leg and focus exclusively on the breathing difficulty. In so doing the physician may fail to recognize the likely symptomatology of DVT/PE. Another side of selective attention comes to the fore when a problem is so pressing that the individual becomes fixated on solving this overriding concern to the detriment of the real solution. As Norman (1) has recounted, divers, struggling to reach the surface of the water, frequently forget to release the weights on their belts which helped them stay down. Similarly, focusing exclusively on keeping blood pressure low during cardiac surgery to avoid heart muscle strain, may miss the need for higher blood pressure to keep the heart muscle supplied with oxygen. As we have seen here the demands on attention are shifting and varied. Depending on previous experience, referred to as schemata by cognitive researchers, multiple stimuli are sorted into familiar patterns that help process them. 1. Norman, DA. 1988. The Psychology of Everyday Things. Basic Books.

10. Perception or Pattern Recognition What is perception? What is pattern recognition? The role of these two constructs in understanding patient safety The role of perception in the experience of every day life has had a distinguished career in philosophy and psychology. For the role of perception and pattern recognition in patient safety however, our goals are less lofty. Instead we shall focus on the practical applicability of these concepts. What then is perception and why is it linked more often than not to pattern recognition? As has become clear from earlier slides, it is far easier to analytically separate the individual components of cognition than to point to their precise sequence in the cognitive process. For the individual, moreover, these processes mostly happen without conscious awareness. Since we are constantly bombarded with a great variety of stimuli, we attend only to those stimuli that we deem important. By recognizing their importance we draw on familiar patterns of experience in which this stimuli or something similar to it occurred. The act of perceiving then is laden with �value judgment,� if you will, as to what the pattern may mean. It is in this coupling of stimuli, perception and pattern, that understanding begins and, with it, decision making. If the process of attending to the patient is interrupted, hurried or displaced from focus by other pressing needs, vitally important clues can go unnoticed. In many instances an initial incorrect diagnosis is not life threatening, but merely an inconvenience to both physician and patient. However, under other circumstances the results can be dire. Lack of knowledge or diagnostic ability is rarely the culprit in mismanagement of patients, rather it is the situational environment or system interference which distorts the assessment of the relevant variables. The role of perception in the experience of every day life has had a distinguished career in philosophy and psychology. For the role of perception and pattern recognition in patient safety however, our goals are less lofty. Instead we shall focus on the practical applicability of these concepts. What then is perception and why is it linked more often than not to pattern recognition? As has become clear from earlier slides, it is far easier to analytically separate the individual components of cognition than to point to their precise sequence in the cognitive process. For the individual, moreover, these processes mostly happen without conscious awareness. Since we are constantly bombarded with a great variety of stimuli, we attend only to those stimuli that we deem important. By recognizing their importance we draw on familiar patterns of experience in which this stimuli or something similar to it occurred. The act of perceiving then is laden with �value judgment,� if you will, as to what the pattern may mean. It is in this coupling of stimuli, perception and pattern, that understanding begins and, with it, decision making. If the process of attending to the patient is interrupted, hurried or displaced from focus by other pressing needs, vitally important clues can go unnoticed. In many instances an initial incorrect diagnosis is not life threatening, but merely an inconvenience to both physician and patient. However, under other circumstances the results can be dire. Lack of knowledge or diagnostic ability is rarely the culprit in mismanagement of patients, rather it is the situational environment or system interference which distorts the assessment of the relevant variables.

11. Cognitive Structures Working memory (WM) Knowledge base (KB) Before addressing mind set or situational models, we need to pause for a moment and familiarize ourselves with how we process information in relationship to our working memory and our knowledge base. In other words, utilization of working memory and knowledge base determines what kind of situational models we are prone to embrace more easily than others. As we go through life, beginning with the various cognitive stages posited by the cognitive psychologist Piaget, our working memory and knowledge base grows and adapts to the circumstances we find ourselves in. Both constructs therefore rely heavily on our experience as well as our innate intellect. Working memory is the conscious sorting through of sensory input. While the operations of the working memory are relatively slow and analytical, the knowledge base uses fast and unconscious heuristics to arrive at its selections. Under time pressure or in cases of limited information, the two most common approaches employed by the knowledge base are matching things with items that are similar and filling in missing pieces with what has worked most frequently in the past. Both operations are known as similarity matching and frequency gambling. Some individuals define frequency gambling as habit intrusion or response bias. In order to activate these cognitive structures, a specific intention has to be present. For example, we do not give thought to picking up a carton of milk at the grocery store. However, if we were to describe in exhaustive detail all the steps this entails, a simple procedure would mushroom into a cumbersome description. The point of all this is to convey how our intentions fall back on cognitive shortcuts previously shown to work in similar situations, thereby saving computational time and not taxing our fragile attention span. But what does this all have to do with patient safety? Before addressing mind set or situational models, we need to pause for a moment and familiarize ourselves with how we process information in relationship to our working memory and our knowledge base. In other words, utilization of working memory and knowledge base determines what kind of situational models we are prone to embrace more easily than others. As we go through life, beginning with the various cognitive stages posited by the cognitive psychologist Piaget, our working memory and knowledge base grows and adapts to the circumstances we find ourselves in. Both constructs therefore rely heavily on our experience as well as our innate intellect. Working memory is the conscious sorting through of sensory input. While the operations of the working memory are relatively slow and analytical, the knowledge base uses fast and unconscious heuristics to arrive at its selections. Under time pressure or in cases of limited information, the two most common approaches employed by the knowledge base are matching things with items that are similar and filling in missing pieces with what has worked most frequently in the past. Both operations are known as similarity matching and frequency gambling. Some individuals define frequency gambling as habit intrusion or response bias. In order to activate these cognitive structures, a specific intention has to be present. For example, we do not give thought to picking up a carton of milk at the grocery store. However, if we were to describe in exhaustive detail all the steps this entails, a simple procedure would mushroom into a cumbersome description. The point of all this is to convey how our intentions fall back on cognitive shortcuts previously shown to work in similar situations, thereby saving computational time and not taxing our fragile attention span. But what does this all have to do with patient safety?

12. Mindset Knowledge in context Mindset in cognition vs. mindset as bias Goal conflicts Unless existing knowledge is used in the appropriate context it remains inert and inaccessible. To activate knowledge it first has to be perceived as relevant. To access all situation-relevant information requires time, especially in complex cases. The more information has to be juggled and sorted simultaneously, the easier it is to overlook something and cope via simplification. Mindset does not exist in isolation but is conditioned by knowledge in context and by the struggle to find accommodations with conflicting goals. Mindset is not rigid but changes in reaction to these dynamic factors. Mindset is the process by which human beings react to an ever changing environment. Mindset therefore should not be confused with our common understanding of bias which is the colloquial understanding of this term. The cognitive mindset�s task is to decide which stimuli are worthy of attention given the present set of goals. If we add to this mix the fact that we frequently operate under conflicting goals, some explicitly spelled out, others tacitly assumed, it is easy to see why there may be information overload and thus a tendency to simplify. Unless existing knowledge is used in the appropriate context it remains inert and inaccessible. To activate knowledge it first has to be perceived as relevant. To access all situation-relevant information requires time, especially in complex cases. The more information has to be juggled and sorted simultaneously, the easier it is to overlook something and cope via simplification. Mindset does not exist in isolation but is conditioned by knowledge in context and by the struggle to find accommodations with conflicting goals. Mindset is not rigid but changes in reaction to these dynamic factors. Mindset is the process by which human beings react to an ever changing environment. Mindset therefore should not be confused with our common understanding of bias which is the colloquial understanding of this term. The cognitive mindset�s task is to decide which stimuli are worthy of attention given the present set of goals. If we add to this mix the fact that we frequently operate under conflicting goals, some explicitly spelled out, others tacitly assumed, it is easy to see why there may be information overload and thus a tendency to simplify.

13. Decision Making Selection of goals and tasks Information processing Limited workspace of the working memory Various heuristics Situational awareness Since we have dealt with the fundamental concepts of cognition, we can now put them all together and see how they affect medical decision making. No decision is made in a vacuum. All decisions are situated in a particular context. To appraise the context correctly, however, requires some selection and processing of information to arrive at an interim conclusion of what is needed. This interim conclusion sets the stage on where to proceed next. While decision making is more consciously explicit, the sizing up of the potential action field is automatic. Once this is done we can focus on the goals and tasks we want to make decisions about. How then does the process play itself out? As we indicated earlier, aware or not, we constantly process stimuli or information. All of this processing is accomplished in the limited workspace of the working memory while simultaneously drawing on various schemata or knowledge structures from our knowledge base. Since the workspace is limited, we can only deal with a maximum of approximately 7 unrelated items in the immediate short term memory. Fortunately, the activities of living are mostly repetitive. We do not have to retrace our cognitive processes anew every time we engage in the same or a similar action. This leaves us free to devote our attention to novel circumstances which our sensory system is designed to detect. This is the positive side of relying on habit patterns or heuristics built on solid experience. The negative side is that it allows us to use shortcuts in complex situations, thereby endangering the accuracy of our assessment. Some of the heuristics we have dealt with before are frequency gambling and similarity matching. Another one utilized is inferential reasoning, that is, to reason from what is known and often represents a particular symptom complex to the unknown. An experienced physician, for example, tends to employ forward reasoning from the data to the diagnosis, whereas an inexperienced physician reasons inferentially backwards from a diagnosis to the data. Depending on the situational analysis, one can expect to see one of three patterns of decision making. This is what we�ll turn to next. Since we have dealt with the fundamental concepts of cognition, we can now put them all together and see how they affect medical decision making. No decision is made in a vacuum. All decisions are situated in a particular context. To appraise the context correctly, however, requires some selection and processing of information to arrive at an interim conclusion of what is needed. This interim conclusion sets the stage on where to proceed next. While decision making is more consciously explicit, the sizing up of the potential action field is automatic. Once this is done we can focus on the goals and tasks we want to make decisions about. How then does the process play itself out? As we indicated earlier, aware or not, we constantly process stimuli or information. All of this processing is accomplished in the limited workspace of the working memory while simultaneously drawing on various schemata or knowledge structures from our knowledge base. Since the workspace is limited, we can only deal with a maximum of approximately 7 unrelated items in the immediate short term memory. Fortunately, the activities of living are mostly repetitive. We do not have to retrace our cognitive processes anew every time we engage in the same or a similar action. This leaves us free to devote our attention to novel circumstances which our sensory system is designed to detect. This is the positive side of relying on habit patterns or heuristics built on solid experience. The negative side is that it allows us to use shortcuts in complex situations, thereby endangering the accuracy of our assessment. Some of the heuristics we have dealt with before are frequency gambling and similarity matching. Another one utilized is inferential reasoning, that is, to reason from what is known and often represents a particular symptom complex to the unknown. An experienced physician, for example, tends to employ forward reasoning from the data to the diagnosis, whereas an inexperienced physician reasons inferentially backwards from a diagnosis to the data. Depending on the situational analysis, one can expect to see one of three patterns of decision making. This is what we�ll turn to next.

14. Situational Analysis and  Decision Style Urgency of the situation Moderate urgency Low urgency While the urgency referred to above is primarily medical in nature, the urgency can also come from other sources such as time pressures not related to the particular case. Under high urgency situations, the decision making process is rapid. These kind of situations are common to emergency rooms and other situations that are life threatening. The most prominent or threatening data is attended to first to avoid further deterioration. Moderate urgency situations apply to less complex cases that have a greater tolerance for deliberation and therefore allow information seeking behavior. These cases are usually treated in the ambulatory care environment. Preventive strategies and annual physicals can be identified as low urgency situations. The decisions made in these circumstances follow well established patterns and require additional investment of decisions only if data is found outside of normal ranges. Please remember, however, that even in these relatively clear cut cases, team performance, fatigue or other stressors can undermine the decision sequence.(1) 1. Patel, VL, Arocha, JF, Kaufman, DR. 1999. Medical Cognition. In. Handbook of Applied Cognition. Ed. FT Durso. Pp. 663-693. . While the urgency referred to above is primarily medical in nature, the urgency can also come from other sources such as time pressures not related to the particular case. Under high urgency situations, the decision making process is rapid. These kind of situations are common to emergency rooms and other situations that are life threatening. The most prominent or threatening data is attended to first to avoid further deterioration. Moderate urgency situations apply to less complex cases that have a greater tolerance for deliberation and therefore allow information seeking behavior. These cases are usually treated in the ambulatory care environment. Preventive strategies and annual physicals can be identified as low urgency situations. The decisions made in these circumstances follow well established patterns and require additional investment of decisions only if data is found outside of normal ranges. Please remember, however, that even in these relatively clear cut cases, team performance, fatigue or other stressors can undermine the decision sequence.(1) 1. Patel, VL, Arocha, JF, Kaufman, DR. 1999. Medical Cognition. In. Handbook of Applied Cognition. Ed. FT Durso. Pp. 663-693. .

15. Situational Factors� Impact on Patient Safety Risk factors in decreasing order of magnitude: Unfamiliarity with the task x17 Time shortage x11 Information overload x 6 Misperception of risk x 4 Inadequate checking x 3 While you only see five situational factors listed above, there are many more. (1) What is noteworthy about these risk factors is not their individual ranking, but their capacity to increase the magnitude of risk when combined. In combination the risk is not simply cumulative; instead it grows almost exponentially. For example, time shortage coupled with information overload does not give you a magnitude of x 17 as the risk, but a risk of about x 50. As you know from your own experience, you are rarely dealing with just one risk factor. 1. Williams J. 1988. A data-based method for assessing and reducing human errors to improve operational performance. In: Hagen W, ed. ILEEE Fourth conference on human factors and power plants. Pp. 200-231. New York: Institute for Electrical and Electronic Engineers. While you only see five situational factors listed above, there are many more. (1) What is noteworthy about these risk factors is not their individual ranking, but their capacity to increase the magnitude of risk when combined. In combination the risk is not simply cumulative; instead it grows almost exponentially. For example, time shortage coupled with information overload does not give you a magnitude of x 17 as the risk, but a risk of about x 50. As you know from your own experience, you are rarely dealing with just one risk factor. 1. Williams J. 1988. A data-based method for assessing and reducing human errors to improve operational performance. In: Hagen W, ed. ILEEE Fourth conference on human factors and power plants. Pp. 200-231. New York: Institute for Electrical and Electronic Engineers.

16. Multiple Steps Error Rates The greater the complexity of the procedure the higher is the probability of error Rates are set at a P value of 0.05 percent 1 step results in 5 percent chance of error 5 steps in 33% chance 25 steps in 72% chance 50 steps in 92% chance As you can see the error rate is directly related to the number of steps required, ranging from 5 percent for one step to 92 percent for 50 steps. (1) One of the reasons medication errors are so frequent is based on this fact. Not only are multiple agents involved in the process but there are also multiple steps. This relationship between errors and steps is one of the reasons that simplification of a complex process is seen as a promising avenue to increase patient safety. (2) Keeping all this in mind we shall now turn to our six clinical cases. Park H. 1997. Human error. In: Handbook of human factors and ergonomics. Salvendy G. ed. Pp. 150-173. New York: Wiley. Nolan TW. 2000. System changes to improve patient safety. BMJ. 320:771-773. As you can see the error rate is directly related to the number of steps required, ranging from 5 percent for one step to 92 percent for 50 steps. (1) One of the reasons medication errors are so frequent is based on this fact. Not only are multiple agents involved in the process but there are also multiple steps. This relationship between errors and steps is one of the reasons that simplification of a complex process is seen as a promising avenue to increase patient safety. (2) Keeping all this in mind we shall now turn to our six clinical cases. Park H. 1997. Human error. In: Handbook of human factors and ergonomics. Salvendy G. ed. Pp. 150-173. New York: Wiley. Nolan TW. 2000. System changes to improve patient safety. BMJ. 320:771-773.

17. Case OneCogan�s Syndrome Rare form of vasculitis Mimics allergic symptoms Results in hearing loss An 18-year-old college student was evaluated because of red eyes, stuffy nose, and difficulty hearing. On examination, there was evidence of conjunctivitis, the tympanic membranes were mildly inflamed, and the nasal mucosa was moist and swollen. A diagnosis of allergic rhinitis was made and she was treated symptomatically. The patient returned to the emergency room two days later unimproved and was evaluated by the same physician. Her nasal and ocular symptoms were essentially the same but her hearing was much worse. Ignoring the complaint of worsening hearing, the physician again diagnosed allergic rhinitis and sent the patient home. A specialist ultimately diagnosed the patient as having Cogan�s syndrome, a rare form of vasculitis, but by then the patient had suffered permanent hearing loss. � An 18-year-old college student was evaluated because of red eyes, stuffy nose, and difficulty hearing. On examination, there was evidence of conjunctivitis, the tympanic membranes were mildly inflamed, and the nasal mucosa was moist and swollen. A diagnosis of allergic rhinitis was made and she was treated symptomatically. The patient returned to the emergency room two days later unimproved and was evaluated by the same physician. Her nasal and ocular symptoms were essentially the same but her hearing was much worse. Ignoring the complaint of worsening hearing, the physician again diagnosed allergic rhinitis and sent the patient home. A specialist ultimately diagnosed the patient as having Cogan�s syndrome, a rare form of vasculitis, but by then the patient had suffered permanent hearing loss. �

18. Case One Take Home Points What are the important take home points from case one? Cogan�s syndrome is a relatively rare disease. Given the fact that the cognitive tendency is to rely on the most common symptoms, initial diagnosis of allergic rhinitis is not unreasonable, though neither rhinitis nor conjunctivitis are associated with difficulty hearing. The initial diagnosis relied on frequency gambling, that is, the thought process fell back on the most common diagnosis associated with this presentation. What was not considered was the hearing difficulty. In general, however, visual stimuli�red eyes, moist and swollen nasal mucosa� take precedence in information processing. Hence the reliance on these visual clues rather than focusing on the hearing difficulty. When the patient failed to improve and returned with worsening hearing symptoms, unfortunately they were again ignored, and the physician failed to revise his or her diagnosis, being fixated on the original diagnosis. (1) Take home points: Consider a new differential diagnosis when the first one fails Focus attention on stimuli originally ignored or dismissed Be mindful of the tendency to go with familiar patterns and remember that, though this habitual way of processing information can be useful most of the time, it can occasionally lead to a wrong conclusion. 1. Zhang, J. 1997. The nature of external presentation in problem solving. Cognitive Science, 21:179-217. Cogan�s syndrome is a relatively rare disease. Given the fact that the cognitive tendency is to rely on the most common symptoms, initial diagnosis of allergic rhinitis is not unreasonable, though neither rhinitis nor conjunctivitis are associated with difficulty hearing. The initial diagnosis relied on frequency gambling, that is, the thought process fell back on the most common diagnosis associated with this presentation. What was not considered was the hearing difficulty. In general, however, visual stimuli�red eyes, moist and swollen nasal mucosa� take precedence in information processing. Hence the reliance on these visual clues rather than focusing on the hearing difficulty. When the patient failed to improve and returned with worsening hearing symptoms, unfortunately they were again ignored, and the physician failed to revise his or her diagnosis, being fixated on the original diagnosis. (1) Take home points: Consider a new differential diagnosis when the first one fails Focus attention on stimuli originally ignored or dismissed Be mindful of the tendency to go with familiar patterns and remember that, though this habitual way of processing information can be useful most of the time, it can occasionally lead to a wrong conclusion. 1. Zhang, J. 1997. The nature of external presentation in problem solving. Cognitive Science, 21:179-217.

19. Case Two: Botulism System pressures � unscheduled office visit Fall back on common diagnosis Diagnosis of viral pharyngitis A 16-year-old boy was worked into the office schedule for a sore throat. The mother was insistent that he be seen. When examined between the regularly scheduled patients, the teenager was seen without the mother present. He complained of a sore throat of one day�s duration, a change in the quality of his voice, and trouble reading the newspaper. The interview and examination were completed in five minutes. The physician did not speak with the mother who was in the waiting room. The physician noted in the medical record that the patient was afebrile, his voice was slightly nasal, and the throat infected, and there was no lymphadenopathy. The patient was diagnosed with viral pharyngitis and sent home with symptomatic treatment. The patient was admitted to the hospital that night with dysphagia, dysarthria, diplopia, and a diagnosis of botulism was made. The mother confirmed that all these symptoms were present in the morning when the patient was brought to the office. � A 16-year-old boy was worked into the office schedule for a sore throat. The mother was insistent that he be seen. When examined between the regularly scheduled patients, the teenager was seen without the mother present. He complained of a sore throat of one day�s duration, a change in the quality of his voice, and trouble reading the newspaper. The interview and examination were completed in five minutes. The physician did not speak with the mother who was in the waiting room. The physician noted in the medical record that the patient was afebrile, his voice was slightly nasal, and the throat infected, and there was no lymphadenopathy. The patient was diagnosed with viral pharyngitis and sent home with symptomatic treatment. The patient was admitted to the hospital that night with dysphagia, dysarthria, diplopia, and a diagnosis of botulism was made. The mother confirmed that all these symptoms were present in the morning when the patient was brought to the office. �

20. Case Two Take Home Points What are the important take home points from case two? Consider that last-minute office visits, like those that are squeezed in, may be especially in need of careful workup. While the teenager was old enough to be seen alone, the presence of the mother would not have slowed down the interview. Indeed she may have argued with the physician that her son must be more ill than viral pharyngitis. The physician�s mind set focused on viral pharyngitis thus not listening to the patient�s complaint of having difficulty reading, a symptom unrelated to pharyngitis. While botulism is not a common disease, the difficulty in reading should have acted as a red flag. The slightly �nasal voice� was the beginning of more severe dysarthria. Take home points: Time pressure increased the probability of missing a key symptom Physician was fixated on the pharyngitis thus not listening to the account of visual loss of function The �nasal voice,� a precursor for more severe dysarthria, was also overlooked. Again a sign of fixation and confirmation bias where contradictory information is ignored Consider that last-minute office visits, like those that are squeezed in, may be especially in need of careful workup. While the teenager was old enough to be seen alone, the presence of the mother would not have slowed down the interview. Indeed she may have argued with the physician that her son must be more ill than viral pharyngitis. The physician�s mind set focused on viral pharyngitis thus not listening to the patient�s complaint of having difficulty reading, a symptom unrelated to pharyngitis. While botulism is not a common disease, the difficulty in reading should have acted as a red flag. The slightly �nasal voice� was the beginning of more severe dysarthria. Take home points: Time pressure increased the probability of missing a key symptom Physician was fixated on the pharyngitis thus not listening to the account of visual loss of function The �nasal voice,� a precursor for more severe dysarthria, was also overlooked. Again a sign of fixation and confirmation bias where contradictory information is ignored

21. Case ThreePneumothorax 64 year old male Shortness of breath� COPD Diagnosis of pneumothorax A 64-year-old male with long standing mild chronic obstructive pulmonary disease made frequent visits and telephone calls to his internist because of shortness of breath. The patient was typically quite anxious and his symptoms responded well to reassurance or to minor changes in his medical program. This pattern persisted for a number of years. Late one evening the physician received a call from the patient�s wife about another episode of shortness of breath. The complaint was typical for the patient, but the call from the patient�s wife was unusual. Without taking a history, once again the physician quickly provided reassurance and suggested an increase in the frequency of his inhaled bronchodilators and that the patient be brought to the office the following morning for a check up. Later that evening the patient was admitted through the emergency department with a pneumothorax. A 64-year-old male with long standing mild chronic obstructive pulmonary disease made frequent visits and telephone calls to his internist because of shortness of breath. The patient was typically quite anxious and his symptoms responded well to reassurance or to minor changes in his medical program. This pattern persisted for a number of years. Late one evening the physician received a call from the patient�s wife about another episode of shortness of breath. The complaint was typical for the patient, but the call from the patient�s wife was unusual. Without taking a history, once again the physician quickly provided reassurance and suggested an increase in the frequency of his inhaled bronchodilators and that the patient be brought to the office the following morning for a check up. Later that evening the patient was admitted through the emergency department with a pneumothorax.

22. Case Three Take Home Points What are the important take home points from case three? The call from the wife was unusual as the patient had never hesitated in the past to contact his physician personally to find reassurance about his symptoms and anxiety. Further, in any case involving COPD, speaking personally with the patient provides important clues as to the seriousness of the breathing difficulty. In all likelihood the patient was barely able to speak and therefore urged his wife to contact the physician. The physician was unable to recognize the deviation from the usual interaction pattern and what might be the reason behind it. The physician�s habitual response pattern prevented him from recognizing the changed clinical picture. The physician acted in an automatic fashion rather than in a problem solving mode. Take home points: Automatic response pattern rather than a problem solving mode Habituation to past patterns thereby failing to recognize the significance of the wife�s calling Failure to listen to the patient deprived the physician of the important clue of breathing difficulty Fixation on COPD The call from the wife was unusual as the patient had never hesitated in the past to contact his physician personally to find reassurance about his symptoms and anxiety. Further, in any case involving COPD, speaking personally with the patient provides important clues as to the seriousness of the breathing difficulty. In all likelihood the patient was barely able to speak and therefore urged his wife to contact the physician. The physician was unable to recognize the deviation from the usual interaction pattern and what might be the reason behind it. The physician�s habitual response pattern prevented him from recognizing the changed clinical picture. The physician acted in an automatic fashion rather than in a problem solving mode. Take home points: Automatic response pattern rather than a problem solving mode Habituation to past patterns thereby failing to recognize the significance of the wife�s calling Failure to listen to the patient deprived the physician of the important clue of breathing difficulty Fixation on COPD

23. Case FourAmyloidosis 70- year old male with congestive heart failure Multiple symptoms all attributed to heart failure Purpura Amyloidosis An internist cared for a 70-year-old man with congestive heart failure. The etiology of the heart failure was unclear. Several months after the onset of heart failure, the patient developed slightly elevated transaminase levels that were attributed to passive liver congestion. The patient then developed trace protein in the urine that was also attributed to heart failure. Next, the patient developed purpura despite a normal platelet count and coagulation studies. This symptom appeared when the physician was coping with a new billing system which prompted the physician to run behind schedule and to feel overwhelmed. He could not immediately identify the significance of this finding and decided that it was unimportant in comparison with the problems associated with CHF. At some later day, the patient developed ascites that were also attributed to heart failure. The care of the patient was transferred to another physician who diagnosed amyloidosis confirmed by a biopsy. � An internist cared for a 70-year-old man with congestive heart failure. The etiology of the heart failure was unclear. Several months after the onset of heart failure, the patient developed slightly elevated transaminase levels that were attributed to passive liver congestion. The patient then developed trace protein in the urine that was also attributed to heart failure. Next, the patient developed purpura despite a normal platelet count and coagulation studies. This symptom appeared when the physician was coping with a new billing system which prompted the physician to run behind schedule and to feel overwhelmed. He could not immediately identify the significance of this finding and decided that it was unimportant in comparison with the problems associated with CHF. At some later day, the patient developed ascites that were also attributed to heart failure. The care of the patient was transferred to another physician who diagnosed amyloidosis confirmed by a biopsy. �

24. Case Four Take Home Points What are the important take home points from case four? The key clue that the patient may have some other problem besides CHF was the appearance of purpura. Recall that the symptom was noted when the physician was laboring under information overload due to a new billing system and pressed for time. Under conditions of stress it is natural to try and simplify the situation. Rejecting the significance of the purpura was such a step. Take home points: Risk factors for errors increase by a magnitude of six under conditions of information overload and by a magnitude of 11 under time pressure (1) Had the physician been mentally prepared for the possibility of error under these conditions, the misdiagnosis might not have occurred 1. Williams J. 1988. A data-based method for assessing and reducing human errors to improve operational performance. In: Hagen W, ed. ILEEE Fourth conference on human factors and power plants. Pp. 200-231. New York: Institute for Electrical and Electronic Engineers. The key clue that the patient may have some other problem besides CHF was the appearance of purpura. Recall that the symptom was noted when the physician was laboring under information overload due to a new billing system and pressed for time. Under conditions of stress it is natural to try and simplify the situation. Rejecting the significance of the purpura was such a step. Take home points: Risk factors for errors increase by a magnitude of six under conditions of information overload and by a magnitude of 11 under time pressure (1) Had the physician been mentally prepared for the possibility of error under these conditions, the misdiagnosis might not have occurred 1. Williams J. 1988. A data-based method for assessing and reducing human errors to improve operational performance. In: Hagen W, ed. ILEEE Fourth conference on human factors and power plants. Pp. 200-231. New York: Institute for Electrical and Electronic Engineers.

25. Case FiveOsteoporosis Breast cancer in the past Arm pain Bone scan shows no metastasis Radiotherapy for pain relief Back pain Again radiotherapy Diagnosis: degenerative weakening, or osteoporosis A prior breast cancer patient developed arm pain. The physician immediately feared that the disease had metastasized. He ordered a bone scan which showed no evidence of metastasis. While bone scans can give false negatives, for a single metastasis the decision to aggressively treat is not indicated until all other possibilities have been ruled out. The physician was convinced that there was metastasis and ordered radiation treatment to relieve the pain. At some later point the patient developed back pain which were also attributed to metastasis. Over several years the patient received chemotherapy and radiation. Only when the patient moved to another state, was it established that she had never suffered from metastases but osteoporosis. Radiotherapy actually contributed to her bone loss.(1) 1. Rees G. 2001. Risk management in clinical oncology. In: Clinical risk management. Enhancing patient safety. Vincent C, ed. Pp. 197-217. London: BMJ Books. A prior breast cancer patient developed arm pain. The physician immediately feared that the disease had metastasized. He ordered a bone scan which showed no evidence of metastasis. While bone scans can give false negatives, for a single metastasis the decision to aggressively treat is not indicated until all other possibilities have been ruled out. The physician was convinced that there was metastasis and ordered radiation treatment to relieve the pain. At some later point the patient developed back pain which were also attributed to metastasis. Over several years the patient received chemotherapy and radiation. Only when the patient moved to another state, was it established that she had never suffered from metastases but osteoporosis. Radiotherapy actually contributed to her bone loss.(1) 1. Rees G. 2001. Risk management in clinical oncology. In: Clinical risk management. Enhancing patient safety. Vincent C, ed. Pp. 197-217. London: BMJ Books.

26. Case Five Take Home Points What are the important take home points from case five? To suspect metastasis in a past cancer patient complaining of pain is a likely first assumption. However, this conclusion needs to be beyond a shadow of a doubt as the consequences for the patient are considerable in both emotional and physical suffering, not to mention potential side effects of the radiation and chemotherapy. Even though the bone scan showed no metastasis, the physician failed to act on this information. His fixation overruled the evidence. In effect he fell back on �pattern matching� and applied a previously useful solution rather than proceed in a true problem solving mode. To make sure that there is cancer, there has to be a �tissue diagnosis� of either tissue or fluid by a pathologist. This is important as an infection can mimic cancer in the bone. Take home points: The physician fell back on confirmation bias by excluding the results of the bone scan The physician showed overconfidence in the diagnosis relying on �frequency gambling� and �pattern matching� rather than true problem solving To suspect metastasis in a past cancer patient complaining of pain is a likely first assumption. However, this conclusion needs to be beyond a shadow of a doubt as the consequences for the patient are considerable in both emotional and physical suffering, not to mention potential side effects of the radiation and chemotherapy. Even though the bone scan showed no metastasis, the physician failed to act on this information. His fixation overruled the evidence. In effect he fell back on �pattern matching� and applied a previously useful solution rather than proceed in a true problem solving mode. To make sure that there is cancer, there has to be a �tissue diagnosis� of either tissue or fluid by a pathologist. This is important as an infection can mimic cancer in the bone. Take home points: The physician fell back on confirmation bias by excluding the results of the bone scan The physician showed overconfidence in the diagnosis relying on �frequency gambling� and �pattern matching� rather than true problem solving

27. Case SixType 1DM, Non-compliant 36-year old African American female with type 1 diabetes mellitus Pattern of extra insulin before coming to the office Local ER twice recently for hypoglycemia Sent to her primary care physician for supervision Next ER visit shows creatinine of 2.0 mg/dl A 36 year old African American woman with a history of type 1 diabetes mellitus since age 9 has been seen in your practice for the past 5 years. She is well known for noncompliance with her insulin regimen, diet, lab tests and eye exams. Her last HbA1c, from a year ago, was 10.9%, urine for microalbuminuria was negative two years ago, and creatinine was 1.2 mg/dL a year ago. She typically will take extra insulin before coming to the clinic in order to �pass� her finger stick testing. Today she is coming in because she has been to her local ER twice in the past three months for severe hypoglycemia. In the ER she was told to follow-up with her primary doctor. You are exasperated. Her finger stick is 120 and she admits that she took half a dose of insulin before coming to the appointment. You exhort her to stop taking insulin on an �as needed basis.� You tell her that she had those episodes of hypoglycemia because she took too much insulin. She does admit that she had restarted her insulin regimen at the same time that all this started. You tell her that you are glad she has decided to be compliant, but that you both need to figure out her �true� insulin needs. You send her home with a promise that she will check her finger sticks regularly and then you will adjust her insulin dose accordingly. A few weeks later the patient had another episode of hypoglycemia, and in the ER a creatinine was drawn with a result of 2.0 mg/dl. She was referred to Nephrology for follow-up and possible future need for dialysis. The physician was so entrenched in the patient�s pattern of noncompliance that the possibility of worsening renal function was overlooked as an important cause of hypoglycemia in an insulin dependent diabetic. A 36 year old African American woman with a history of type 1 diabetes mellitus since age 9 has been seen in your practice for the past 5 years. She is well known for noncompliance with her insulin regimen, diet, lab tests and eye exams. Her last HbA1c, from a year ago, was 10.9%, urine for microalbuminuria was negative two years ago, and creatinine was 1.2 mg/dL a year ago. She typically will take extra insulin before coming to the clinic in order to �pass� her finger stick testing. Today she is coming in because she has been to her local ER twice in the past three months for severe hypoglycemia. In the ER she was told to follow-up with her primary doctor. You are exasperated. Her finger stick is 120 and she admits that she took half a dose of insulin before coming to the appointment. You exhort her to stop taking insulin on an �as needed basis.� You tell her that she had those episodes of hypoglycemia because she took too much insulin. She does admit that she had restarted her insulin regimen at the same time that all this started. You tell her that you are glad she has decided to be compliant, but that you both need to figure out her �true� insulin needs. You send her home with a promise that she will check her finger sticks regularly and then you will adjust her insulin dose accordingly. A few weeks later the patient had another episode of hypoglycemia, and in the ER a creatinine was drawn with a result of 2.0 mg/dl. She was referred to Nephrology for follow-up and possible future need for dialysis. The physician was so entrenched in the patient�s pattern of noncompliance that the possibility of worsening renal function was overlooked as an important cause of hypoglycemia in an insulin dependent diabetic.

28. Case Six Take Home Points What are the important take home points from case six? Although the patient�s history strongly points to non-compliance as the likely reason for the hypoglycemia, it is useful to look for other causes. The patient has had a history of type 1 diabetes from the age of 9 , that is a total of 27 years. Loss of kidney function therefore may be one of the reasons. Her kidney function, as shown by the creatinine level of 2.00 mg/dl, has dropped almost 50% causing the high levels of insulin which, in turn, resulted in hypoglycemia. The physician relied on his biased memory of past events, sometimes referred to as fixation. Take home points: The physician was fixated on the non-compliance of the past Always check out assumptions about causation. Just because something was true in the past does not make it true today The physician never requested the ER records Although the patient�s history strongly points to non-compliance as the likely reason for the hypoglycemia, it is useful to look for other causes. The patient has had a history of type 1 diabetes from the age of 9 , that is a total of 27 years. Loss of kidney function therefore may be one of the reasons. Her kidney function, as shown by the creatinine level of 2.00 mg/dl, has dropped almost 50% causing the high levels of insulin which, in turn, resulted in hypoglycemia. The physician relied on his biased memory of past events, sometimes referred to as fixation. Take home points: The physician was fixated on the non-compliance of the past Always check out assumptions about causation. Just because something was true in the past does not make it true today The physician never requested the ER records

29. Organizational Stressors and Human Cognition Clinical decisions embedded in: Organizational stressors Psychological interaction Human cognition As we have seen all medical decisions are shaped by a variety of factor. Some of these are our innate capacity to process information and how we react to stress, be it personal or organizational. Errors cannot be eliminated; by accepting this fact, however, we do not point to the individual physician but look for the multiple contributing causes behind the event. As James Reason, the elder statesman of the study of errors, says, �The important challenge is not to eliminate fallibility, but to minimize its damaging consequences.� As we have seen all medical decisions are shaped by a variety of factor. Some of these are our innate capacity to process information and how we react to stress, be it personal or organizational. Errors cannot be eliminated; by accepting this fact, however, we do not point to the individual physician but look for the multiple contributing causes behind the event. As James Reason, the elder statesman of the study of errors, says, �The important challenge is not to eliminate fallibility, but to minimize its damaging consequences.�

30. If To Err Is Human, How �? Ability to adjust to situations that go awry Individual variability as defense against systems errors In this presentation we have focused on how human cognition, sometimes referred to as human factors, contributes to our understanding of patient safety. We now need to take a look at the opposite side of the coin. If it is a natural tendency for human beings to err, logically one can ask, how are so many potential errors intercepted at the last minute? Here we come to the remarkable ability of human beings to adjust and to improvise in unexpected circumstances. As Karl Weick from the University of Michigan emphasizes, variability may be the best defense for a system gone awry.(1) The task then is to find the right balance between systems thinking and the preservation of individual autonomy and variability. 1.)Weik KE. 1987. Organizational culture as a source of high reliability. California Management Review. 29:112-27. In this presentation we have focused on how human cognition, sometimes referred to as human factors, contributes to our understanding of patient safety. We now need to take a look at the opposite side of the coin. If it is a natural tendency for human beings to err, logically one can ask, how are so many potential errors intercepted at the last minute? Here we come to the remarkable ability of human beings to adjust and to improvise in unexpected circumstances. As Karl Weick from the University of Michigan emphasizes, variability may be the best defense for a system gone awry.(1) The task then is to find the right balance between systems thinking and the preservation of individual autonomy and variability. 1.)Weik KE. 1987. Organizational culture as a source of high reliability. California Management Review. 29:112-27.

31. Patient Safety Interactive Learning Community (PSILC) http://www.acponline.org/ptsafety The Patient Safety Interactive Learning Community (PSILC � pronounced like �silk�) has its home page on the ACP-ASIM website. The PSILC website has the content of all seven patient safety modules. It also has a patient safety tip of the week, frequently asked questions, and links to additional information on patient safety. In a few weeks, you�ll be enrolled in our patient safety email discussion group. The email group will allow you to discuss with your colleagues and patient safety experts patient safety issues you�re facing in your practice. We hope to hear a lot of success stories as well any problems/issues that you may be facing. If you decide you don�t want to participate, you�ll also have a chance to �opt-out� of this group at anytime. The Patient Safety Interactive Learning Community (PSILC � pronounced like �silk�) has its home page on the ACP-ASIM website. The PSILC website has the content of all seven patient safety modules. It also has a patient safety tip of the week, frequently asked questions, and links to additional information on patient safety. In a few weeks, you�ll be enrolled in our patient safety email discussion group. The email group will allow you to discuss with your colleagues and patient safety experts patient safety issues you�re facing in your practice. We hope to hear a lot of success stories as well any problems/issues that you may be facing. If you decide you don�t want to participate, you�ll also have a chance to �opt-out� of this group at anytime.

32. Refresher Exercises http://www.acponline.org/ptsafety We're also planning something new to follow up on this session, which is an online refresher exercise. In 2-3 weeks we'll send you an email invitation that will lead to a few questions that will exercise your understanding of what you learned today. After you answer them you'll have a chance to review the slides from this talk related to each question. We hope that you'll all give this a try because this kind of exercise after a time delay is probably the most efficient way to really learn a topic well. We're also planning something new to follow up on this session, which is an online refresher exercise. In 2-3 weeks we'll send you an email invitation that will lead to a few questions that will exercise your understanding of what you learned today. After you answer them you'll have a chance to review the slides from this talk related to each question. We hope that you'll all give this a try because this kind of exercise after a time delay is probably the most efficient way to really learn a topic well.