Marjorie Stiegler, M.D. and Sara Goldhaber-Fiebert, M.D.
Instructor Guide for Understanding and Preventing Cognitive Errors in Healthcare Video
Resources
1. Trigger Video of Understanding and Preventing Cognitive Errors in Healthcare
2. Powerpoint of Key Concepts
3. “Illness Script” PDF
4. Instructor Guide including references for further reading
Background
This brief animated video, filmed at the Stanford University School of Medicine’s Immersive Learning as a collaboration between Stanford and UNC physicians, describes some introductory concepts about medical decision making errors and strategies to avoid them. The impetus for creating it was the recent focus in safety literature about diagnostic delay and misdiagnosis as a major sphere of medical error, and the small but growing number of manuscripts dedicated to exploring cognition and medical decisions. This trigger video is a first step in addressing these concepts in an accessible way for learners and clinical teachers, and serves as a springboard for discussion in many educational settings.
Purpose
Provide a venue for talking about the principles of decision making and cognition, as well as the vulnerabilities for error that are rooted in human nature biases. This trigger video provides an appropriate context for resident trainees, medical students, or any clinicians, to discuss examples of decision making strategies and errors in action.
Objectives:
1. To differentiate the concept of cognitive error from other types of error in medical decision making and behavior
2. To define specific underpinnings of cognitive error and identify them in one’s own practice
3. To identify strategies for prevention of and earlier recovery from cognitive error
How and When to Use
We are now using this as a trigger video for interactive discussion in resident simulation training courses at the University of North Carolina at Chapel Hill and at Stanford University School of Medicine. We do not present it as a comprehensive catalogue or discussion, but rather as an appetizer portion of behavior science applied to medical decision making. Participants are encouraged to discuss how specific principles apply in their own practices, as well as to identify other decision making errors that have occurred. The act of exploration and naming of cognitive phenomena helps to create broad-reaching principles of decision making that can be applied to a variety of clinical situations. As well, naming of these phenomena normalizes the human experience of making an error in diagnosis, treatment, and judgment.
Incorporating the video into a simulation debriefing session is best done with dedicated time to explore the concepts, roughly 30 minutes. The video is also appropriate as a trigger for discussion in larger audiences, such as at Morbidity and Mortality Conference, or other teaching
session. One faculty facilitator is sufficient, provided they are familiar with the video and its principles, expanded in the references listed here. A supplemental powerpoint slide deck is included to highlight core principles, such as the myriad of influencers on decision behavior and thus, cognitive error, as well as the concept of error blindness. The powerpoint is best as an adjunct to the video, and best introduced after viewing the video. Additionally, a PDF exploring the topic of “Illness Scripts” is included, which describes the cognitive consolidation of analytical processes with experience. Illness Scripts represent Type I thinking (as discussed in the video), and may be prone to error in the context of availability bias and memory errors.
We have found that encouraging participants to discuss prior mistakes they have made themselves or heard about others making during emergencies or critical cases is good way to start the session. They will often provide details of the obstacles which they felt contributed to inadequate delivery of high-quality patient care. These details in turn set the stage for discussing concepts of cognitive error in contrast to knowledge gaps or lack of vigilance.
Here we include specific contexts and uses of these materials, including questions for effective discussion:
Ideas for contexts in which video (in whole or in part) may be useful as a trigger for further discussions:
· Simulation course for any learner audience, with one of the explicit learning objectives being awareness of cognitive errors and tools for protecting patients from the effects of clinician cognitive errors
· Case Conference or Problem Based Learning session in which an explicit learning objective is to understand how heuristics may lead to error when diagnoses are selected prematurely based on “classic” pattern matching
· Morbidity & Mortality cases that contain potential cognitive errors
Potential learner audiences are vast and include:
· Pre-clinical medical students
· Residents and fellows
· Mixed-level rounding teams (including clinical medical students, residents, and fellows led by attending or senior trainee)
· CME conferences
· Courses for board-certified physicians or other fully trained clinicians
· Inter-professional teams discussing/practicing teamwork and communication
Suggested questions facilitator may ask after learners view the video to spur discussion:
· Has anyone ever had a case where the “obvious” diagnosis turned out to be incorrect?
· Has anyone ever been involved in a case in which the diagnosis was delayed because it was deemed too unlikely (ie, “common things are common”)?
· Has anyone ever been involved in a case in which a team member expressed a preference for a plan because they “had been burned” by another choice in the past? These kinds of emotional memories do not change the statistical likelihood of recurrence.
· Has anyone ever been involved in a case in which some element of a handoff or transition of care was erroneous, and yet became “sticky”, continuing to propagate in the chart and in the medical decisions?
· How often do you question your own “rightness” when the elements all seem to fit together in an expected way? Is there utility in practicing that kind of self-contrarianism?
Note: we always teach that emergency manuals and cognitive aids do not replace constant clinical judgment and broad situational awareness, and include caveat that it is one of many tools to improve team delivery of care to patient. A key feature is to always reassess if patient not improving as expected. Cognitive error counterbalancing strategies are particularly important in this context.
Effectiveness and Significance
Trainees have given positive feedback about the content of this video, and clinicians of many different specialties and professions have given similarly positive feedback in the context of national workshops and other presentations of the content. One surgeon, with a forty year career, reported that he felt the process of understanding a mistake he had made years ago and carried with him as a burden for decades was cathartic and normalizing. The same is true for trainees.
Limitations
1. The video should not be presented as a comprehensive treatment of cognitive error or prevention strategy. Rather, in combination with references listed below, learners should explore the broad concepts, and reflect upon their own experiences (personal and vicarious) to identify the impact of these cognitive phenomena.
2. While the video can be effectively used for teaching within any medical discipline e.g. Internal Medicine, Intensive Care Unit, Emergency Department, etc. and interprofessional colleagues, e.g. nurses within single disciplines or interdisciplinary teams) the intraoperative setting would be most familiar to Anesthesia and Surgery trainees or clinicians.
Acknowledgments: We thank Stanford University’s Vice Provost for Online Learning as well as each of our departments for their support, Stanford Medicine Educational Technology for video editing, and Kevin Ang for graphic Illustrations. We also greatly appreciate the ideas and input of our predecessors, colleagues, and students who helped to refine the ideas presented here.
References
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