Role of cognition in generating and mitigating clinical errors.
Given the complexities of current clinical practice environments, strategies to reduce clinical error must appreciate that error detection and recovery are integral to the function of complex cognitive systems. In this review, while acknowledging that error elimination is an attractive notion, we use evidence to show that enhancing error detection and improving error recovery are also important goals. We further show how departures from clinical protocols or guidelines can yield innovative and appropriate solutions to unusual problems. This review addresses cognitive approaches to the study of human error and its recovery process, highlighting their implications in promoting patient safety and quality. In addition, we discuss methods for enhancing error recognition, and promoting suitable responses, through external cognitive support and virtual reality simulations for the training of clinicians.
Center for Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York, New York, USA Department of Biomedical Informatics, Arizona State University, Phoenix, Arizona, USA.
Vimla L
VL
Patel
Center for Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York, New York, USA Department of Family Medicine, College of Medicine, University of Illinois at Chicago, Illinois, USA.
Thomas G
TG
Kannampallil
Department of Biomedical Informatics, Arizona State University, Phoenix, Arizona, USA.
Edward H
EH
Shortliffe
D002985:Clinical Protocols; D003071:Cognition; D006801:Humans; D007858:Learning; D019300:Medical Errors / Q000517:prevention & control* / Q000523:psychology*; D017410:Practice Guidelines as Topic; D017751:Safety Management / Q000458:organization & administration* / Q000592:standards
Complexity; Human error; Medical education; Patient safety; Safety culture