title: Prospective memory failures as an unexplored threat to patient safety: results from a pilot study using patient simulators to investigate the missed execution of intentions.
abstract: This study investigated failures of prospective memory (PM) as a relevant but neglected error type in medicine. A patient simulator was used to investigate PM failures. The influence of subjective importance (high, low) and type of intention (educational, internal, external) on the (missed) execution of intention was investigated in a 2 x 2 design. The effects on missed executions by importance (high < low) and type of intention (educational < external < internal) were hypothesized. Of 73 valid intentions in 40 prepared simulator scenarios 19 (26%) were missed overall. A total of 64% of unimportant and 80% of important intentions were executed 79% of educational 67% of external and 72% of internal intentions were executed. Neither difference was statistically significant using chi(2) tests. Interaction was significant for missed executions (p = 0.025; n = 19; df = 2; chi(2) = 7.41) and for executions (p = 0.002; n = 54; df = 2; chi(2) = 12.50). Despite low statistical support and some methodological limitations, it was possible to show that PM failures are relevant to patient safety and that patient simulators are a suitable but so far unused tool for their investigation.
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, Center for Patient Safety and Simulation, University Hospital Tuebingen, University of Tuebingen, Medical School, D-72076, Tuebingen, Germany. peter.dieckmann@med.uni-tuebingen.de
authors.forename: P
authors.initials: P
authors.lastname: Dieckmann
authors.forename: S
authors.initials: S
authors.lastname: Reddersen
authors.forename: T
authors.initials: T
authors.lastname: Wehner
authors.forename: M
authors.initials: M
authors.lastname: Rall
mesh_terms: D000761:Anesthesia Department, Hospital / Q000592:standards*; D003071:Cognition; D006804:Ergonomics; D005858:Germany; D006785:Hospitals, University; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units / Q000592:standards*; D033182:Intention; D019300:Medical Errors / Q000523:psychology*; D008568:Memory; D016544:Patient Simulation; D010865:Pilot Projects; D012449:Safety; D011795:Surveys and Questionnaires; D013597:Systems Analysis; D013647:Task Performance and Analysis; D013997:Time Factors