title: Recognizing and managing errors of cognitive underspecification.
abstract: OBJECTIVE
  James Reason describes cognitive underspecification as incomplete communication that creates a knowledge gap. Errors occur when an information mismatch occurs in bridging that gap with a resulting lack of shared mental models during the communication process. There is a paucity of studies in health care examining this cognitive error and the role it plays in patient harm. The goal of the following case analyses is to facilitate accurate recognition, identify how it contributes to patient harm, and suggest appropriate management strategies.
  
  
  METHODS
  Reason's human error theory is applied in case analyses of errors of cognitive underspecification. Sidney Dekker's theory of human incident investigation is applied to event investigation to facilitate identification of this little recognized error.
  
  
  RESULTS
  Contributory factors leading to errors of cognitive underspecification include workload demands, interruptions, inexperienced practitioners, and lack of a shared mental model. Detecting errors of cognitive underspecification relies on blame-free listening and timely incident investigation. Strategies for interception include two-way interactive communication, standardization of communication processes, and technological support to ensure timely access to documented clinical information. Although errors of cognitive underspecification arise at the sharp end with the care provider, effective management is dependent upon system redesign that mitigates the latent contributory factors.
  
  
  CONCLUSIONS
  Cognitive underspecification is ubiquitous whenever communication occurs. Accurate identification is essential if effective system redesign is to occur.
authors: From the New York University, College of Nursing, New York, New York.
authors: Elizabeth A
authors: EA
authors: Duthie
mesh_terms: D003073:Cognitive Dissonance; D003142:Communication; D005260:Female; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control*; D008962:Models, Theoretical; D010348:Patient Care Team / Q000458:organization & administration; D011369:Professional-Patient Relations; D012107:Research Design; D016526:Workload