THIRD

Cognitive errors are unconscious biases adversely influencing clinical

judgment and leading to diagnostic error.

They often involve heuristics, mental shortcuts formed based on patterns

and learned associations.

Heuristics represent fast, unconscious thinking (eg, impulse) rather than

measured, rational analysis; physicians who are fatigued or who work in
busy clinical settings are more likely to rely on heuristics to increase
diagnostic efficiency.

occurring when initial impressions prematurely influence the diagnosis and

prevent careful consideration of other possibilities

Diagnostic errors

(ie, missed or delayed diagnoses) are often caused by misinterpretation of

clinical data, and account for up to 17% of hospital adverse events.
They can arise from factors relating to the physician (eg, fatigue), the patient
(eg, language barrier), or the system (eg, inefficient workflow).

*several types of cognitive bias:

● Framing bias occurred as the context of information (ie, medical

record describing panic attack history and diagnosis of generalized
anxiety disorder) incorrectly limited the physician's "frame" of
analysis. This bias led to the assumption that tachycardia, shortness
 of breath, and anxiety also represented a panic attack, rather than
possible pulmonary embolism.

● Anchoring bias led to the physician fixating ("anchoring") on a

presumptive diagnosis of panic attack without considering alternate
causes.

● Confirmation bias resulted in the physician's oversight of information

contradicting the presumptive diagnosis, including the patient's risk
factors of smoking and oral contraceptive use.

Availability bias (or "recency effect")

occurs when a memorable ("high-stakes"), often recent case biases

subsequent judgment and decision-making.
This physician's recent experience created a mental heuristic to order head CT
scans on

availability bias commonly causes excessive diagnostic workup and

overtreatment.

Cognitive bias can be minimized by

1-increasing physician awareness (eg, morbidity and mortality meet

ings),
2-encouraging systematic analysis (eg, quick-access electronic tools to
calculate pre-test probability),
3- optimizing the environment (eg, additional staff to reduce physician burden).

* Data misinterpretation, a cause of diagnostic error, may result from

cognitive bias. For example, confirmation bias can result in overlooking
potentially concerning information on imaging or laboratory data in a patient
with headache.
Data misinterpretation and confirmation bias may have triggered the
physician's initial missed diagnosis.

Triage cueing results?

when the diagnostic evaluation is overly influenced by the patient's triage

category.

For example, a physician may miss concerning signs in a patient who is

triaged as low acuity by another staff member.

Implicit bias describes subconscious alterations in thoughts and attitudes

toward specific groups (eg, ethnicity, socioeconomic status, age).

For ex. associating faces belonging to the ethnic minority group with
negative words (eg, "drug-seeking"). subconscious attitudes toward specific
groups (eg, ethnicity),

Implicit bias perpetuates health disparities by subtly but systematically altering

provider-patient interactions (eg, communication style, diagnostic workup);
therefore, organizational action addressing implicit bias is indicated .
According to the Joint Commission, implicit bias can be addressed by the
following measures:
● Assess for bias: Implicit bias uses heuristics (eg, fast thinking or
mental shortcuts); therefore, it is frequently measured using rapid
image association tests (eg, Implicit Association Test), as described in
this study.
● Encourage awareness and collaborative discussion of implicit biases:
In this case, group debriefing on the study results is the best next
step.
● Train clinicians in metacognition (ie, self-monitoring cognitive
patterns): This process can reduce automatic, unconscious reliance
on stereotypes and flawed patterns (common in complex, busy
settings).
●

*A negligent event is an adverse event arising from a clear violation of

standards of care by an individual.
 *A near-miss ("close call")
is when a negative outcome could have occurred but did not, either by chance
or due to timely intervention (eg, a provider orders penicillin for a patient with a
penicillin allergy, but the medication is not administered because the patient's
nurse notes the allergy and alerts the provider about the error). As with control
chart analysis and RCA, near-miss analysis is performed retrospectively and
would not be applicable for this ICU that has not yet begun operations.

A near-miss analysis
is used following a "close call," an event that could have resulted in patient
harm but was prevented in time, such as when an incorrect medication dose is
ordered for a patient, but the error is detected by the nurse before
administration.

Retained surgical objects (RSO)

(eg, sponges, instruments) carry potentially serious patient consequences (eg,
infection, reoperation).
To detect RSO, hospitals typically require 2 nurses to reconcile counts of
objects and instruments used during surgery. However, counting can be
tedious, time-intensive, and error-prone; up to 80% of RSOs occur in cases
that include an appropriate reconciliation count.

Distractions and interruptions are a major contributor to counting errors. At

this hospital, nurses are frequently interrupted by surgeons needing items (eg,
tools, sutures) to close the incision, and the surgeons, who are concentrating
on operative tasks, may be unaware that nurses have initiated the count.

To reduce counting errors, a brief time-out (ie, a dedicated pause where

nurses announce that a final count is about to begin) may be performed to
improve team awareness. This can reduce counting errors through the
following:
● Makes team members aware that an important safety action is about
to begin, and that they should limit unnecessary interruptions
● Allows the surgeons to request anticipated tools and items before the
count, reducing interruptions once the count has started.

**Didactic training addresses knowledge deficiency and may increase the

student's theoretical understanding , but would not address inadequate team
leader support during his first practical attempt.
***how to disclose error When multiple physicians are involved in a patient's
care?

>cooperative disclosure of a serious adverse event to the patient or family is

recommended.

This practice increases transparency (ie, accurate exchange of information)

and achieves the following objectives:

● Promoting continuity of care and reassuring the patient and family

that all the physicians are working for the patient's well-being

● Offering a unified and coordinated explanation of the error and next

steps (eg, consistent explanation of events, expectations for recovery)

● Facilitating an efficient response to patient or family questions and

concerns (eg, all team members are present to provide information
relevant to their area of expertise)
● Promoting a culture of safety (eg, safety as a collective goal) rather
than a culture of blame (eg, attributing error to an individual)

All physicians involved in this patient's initial care (eg, anesthesiologist,

orthopedic surgeon) and in the response to the adverse event (eg,
otolaryngologist) should collectively disclose the adverse event to the family

*Duplicate charts should not be created due to safety concerns (eg, incomplete
charts, conflicting information between charts).

* Redundancy (ie, multiple staff reviewing charts) can reduce errors, but it
is likely impractical in this busy setting and less effective than physical redesign
because it relies on additional human effort.

* Visit summaries, which contain detailed patient information belonging to the

patient's medical record, are not generally intended to be reviewed by
employers. When a patient requires extended medical leave (eg, through the
Family Medical Leave Act), the physician's disclosure of pertinent health
information (with patient consent) is typically limited to information requested
(eg, date of disability onset, nature of limitations) on a standard, employer-
generated form.
If error is adverse event what to do ?
Due to the unpredictable nature of shoulder dystocia, all staff members (eg,
nurses, obstetricians) require training at routine intervals to refresh clinical
knowledge and technical skills. Simulation-based training (SBT) is
particularly helpful because team members can train together and gain hands-
on practice using simulated patient scenarios. This approach improves team
performance (eg, rapid, coordinated response) and technical skills (eg,
maneuvers to resolve dystocia). Scheduled SBT sessions have been associated
with reduced rates of neonatal complications (eg, brachial plexus injury)
from shoulder dystocia

*Tongue laceration is a rare but potentially serious adverse event (ie,

iatrogenic injury not due to patient underlying disease) associated with
endotracheal intubation. The resulting bleeding can be severe, requiring
emergency tracheostomy. Although the risk can be reduced (eg, by using
fiberoptic intubation for high-risk patients), tongue laceration can occur, even
with appropriate preparation and physician experience.
Prevention of sentinel events requires systems-based strategies that
anticipate, detect, and correct error.
Time-out and site verification procedures are critical safety practices that
emphasize team communication and redundancy. These procedures involve
the following:
● Preoperative verification of operative site and patient identity (using
2 identifiers) by at least 2 providers: This process should involve the
patient (or surrogate).
● Site marking, in which the surgeon clearly marks each operative site
with permanent marker: Nonoperative sites should not be marked
because doing so may cause ambiguity (Choice E).
● Final time-out immediately prior to incision involving the entire
team: This verifies surgical site, surgery side, and patient identity.
The final time-out procedures should include the entire surgical team
because all members share responsibility for monitoring for safety and
discrepancies may be detected by any personnel (regardless of experience).
The length of time-out procedures should not be limited because all concerns
or questions from team members must be addressed before beginning the
procedure.

The value of this intervention is determined by comparing changes in

quality outcomes (eg, reoperation rate) to total costs of care per patient.

Value is defined as the ratio of quality to costs:

● Quality includes patient outcomes (eg, mortality, morbidity), safety

(eg, adverse events), and patient care metrics (eg, patient
satisfaction, wait times).

● Costs include the total costs (ie, not only short-term costs) of care
per patient over the entire course of treatment. Costs may be
assessed from the perspective of the patient, health care system, or
 ●

society at large.

Value is better assessed by comparing changes in quality

outcomes to total (eg, including long-term) costs per patient.

High-value health care optimizes quality while minimizing total costs and waste
(ie, avoiding unnecessary treatment or complications).

short-term costs may be offset by lower long-term costs

(eg, from fewer surgical complications and unnecessary reoperations, creating
opportunities for other surgeries).

The variation of health care among physician for same medical

condition ??

>>High variation in care of medical conditions for which well-established

practice guidelines exist is generally associated with unnecessary use (eg,
overuse) of services and lower quality and lower value (ie, quality of care
relative to costs) of care.

For example, evidence-based guidelines support vaginal versus cesarean

delivery for most low-risk pregnancies (ie, nulliparous, term, singleton, and
vertex [NTSV] presentations) and recommend an optimal cesarean delivery rate
for NTSV presentations of ~16%.

However, cesarean delivery rates vary by up to 60% among hospitals in similar

geographic areas, even after adjusting for patient and hospital factors.
Unnecessary cesarean delivery (eg, as seen at this hospital) is associated with
increased costs (eg, cesarean delivery is up to 50% more expensive than
vaginal delivery) and unimproved or worse maternal (eg, infection, need for
emergency hysterectomy) and fetal (eg, respiratory distress) outcomes

What will lead to the variation in clinical performance ??

For example ,,,

rates of cesarean delivery for low-risk pregnancies can vary significantly
among obstetricians at the same hospital.
Evidence suggests that differences in provider practice styles (ie, subjective
decision-making, attitudes, and perceptions about treatment) is the leading
contributor to variation in clinical performance.
Physicians are often highly focused on the care of the individual patient and
may be unaware of how their practice styles quantitatively compare with
evidence-based standards.

Provision of data-driven feedback on a physician's individual clinical

performance (eg, cesarean delivery rates) compared to benchmarks and peers
is effective in optimizing physician practice quality (eg, reducing
unnecessary cesarean delivery). Increasing physician awareness of how their
practice pattern differs from recognized standards can increase attentiveness
in clinical decision-making and promote care that is better aligned with
evidence-based guidelines.

Data-driven feedback has been shown to be more effective than passive

educational strategies (eg, expert-led workshops) in optimizing physician
decision-making.

**When systemic problems with health care quality are observed, the
following approach should be used:

1-communication with relevant stakeholders

2-coordinated efforts (eg, involving both inpatient and outpatient
physicians)
3- team-based interventions to promote shared goals.

RANDOM

*Didactic training
may be appropriate to remedy knowledge deficiency (eg, inappropriate
antibiotic selection) or in error-prone settings (eg, adoption of new electronic
medical record system) but is generally inferior to hands-on, experiential
learning (eg, training using team-based simulation).

*Time off or sleep breaks

can address provider fatigue, a major cause of human error. This error
occurred at the beginning of the resident's shift, making fatigue a less likely
cause; fatigue would also not explain why the error went unnoticed for 2 days.

*Requiring verbal approval from a specialist promotes safety, as it introduces

redundancy (ie, adding multiple checkpoints) before potentially dangerous
interventions.

* Documentation error involves inaccurate or incomplete record-keeping (eg,

not documenting pertinent physical examination findings, copy-and-pasting
outdated information).

*Knowledge deficiency (eg, insufficient ability to interpret clinical data)

is a rarer cause of diagnostic error for practicing physicians compared with
cognitive error.

*Information bias describes the belief that more data is better, leading to
overcollection of data, which can complicate efficient and accurate decision-
making. an excessive, amount of data for diagnostic workup.

*Latent errors are system-level factors, such as inefficient protocols or

organizational structures, that cause adverse events. This case represents an
active error (ie, relating to the physician's specific actions or judgement)
caused by cognitive bias, rather than a system-level error.