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Showing results for tags 'Cognitive tasks'.
Found 27 results
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Content ArticleMedical errors are major hazards, and lapses in non-technical skills such as situational awareness contribute to most incidents. Risks are concentrated in acute care, and in crisis situations clinicians can apparently ignore vital information. Poor workplace ergonomics contributes to risk. Existing work into perceptual errors offers insights, but these phenomena have been little researched in medicine. This thesis considers medical non-technical skills and how they are taught, and explores vulnerability to inattentional and change blindness.
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EventuntilImpartiality is central to the role of an investigator working to understand how a health event occurred. Achieving impartiality is a difficult task as the psychological research demonstrates how experts' perceptions and cognitions are affected by context, motivation, expectation, and experience. A growing body of research has revealed the many sources of bias that affect experts' judgments as they perform their work. These sources of bias extend beyond the characteristics of the individuals who were involved in the event being investigated and include such things as the features of the information being considered, the reference materials, the investigative environment, and an individual’s base-rate expectations. Professionals in fields such as forensic science, intelligence analysis, criminal investigation, and judicial decision-making are at an inflection point where they are considering both their current practices and new approaches. The investigation of health-related events is a professional domain that is in many ways analogous to the aforementioned decision-making environments. Yet, this investigation environment is also unique, as the sources, magnitude, and direction of bias are specific to the workplace setting. This presentation will explore the broad issue of cognitive bias in investigative decision making, discussion sources of investigative bias, and offer suggestions to mitigate the effect of bias in an occupational health investigation. Register
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Content Article
Working under pressure: Performance infographics
Patient Safety Learning posted an article in Good practice
Core Cognition have produced some helpful infographics for staff working under pressure, including fatigue and cognitive performance, cognitive biases and diagnostic error and8 tools to improve communication under pressure, -
Content ArticleDiagnostic errors are the number one patient safety concern in healthcare today, inflicting harm on hundreds of thousands of patients in the USA annually. The problem is complex and involves the difficulties inherent in diagnosis generally, the known weaknesses of human cognition and the myriad breakdown points in our healthcare systems. In this BMJ Editorial, Mark Graber discusses the advantages of clinical decision support tools for diagnosis (CDS-Dx) and three promising trends regarding the uptake and potential use of CDS-Dx systems. Further reading: Co-development of OurDX - an online tool to facilitate patient and family engagement in the diagnostic process
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Content ArticleErrors in clinical reasoning occur in most cases in which the diagnosis is missed, delayed or wrong. The goal of this review from Graber et al., published in BMJ Quality & Safety was to identify interventions that might reduce the likelihood of these cognitive errors. The authors identified a wide range of possible approaches to reduce cognitive errors in diagnosis. Not all the suggestions have been tested, and of those that have, the evaluations typically involved trainees in artificial settings, making it difficult to extrapolate the results to actual practice. Future progress in this area will require methodological refinements in outcome evaluation and rigorously evaluating interventions already suggested, many of which are well conceptualised and widely endorsed.
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RCOG: Video briefing on human factors and situational awareness
Claire Cox posted an article in Maternity
Each baby counts is the Royal College of Obstetricians and Gynaecologist's national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. Watch the Each baby counts human factors video for information on how to address issues within your unit. Key themes: Situational awareness Handover resources Interruptions and distractions Delegation Task-fixation, helicopter view & closed-loop communication Ask for help. -
Content Article
A reflective account of the culture of fear
Anonymous posted an article in Bullying and fear
This is my story of how one bad experience can lead to another. We talk a lot about patients and their safety (quite rightly so) but very rarely do we hear about the healthcare professional who is going through turmoil and their mental health. This is my story. I started my career in a care of the elderly ward (geriatrics), which was exciting as my first job, and I felt that my time management needed to be worked on prior to me starting my career in what I knew at the time to be emergency nursing. I stayed in this area for a year, taking charge of the shift and also managing a bay of eight patients, which was the norm (or so I thought). After about 1 year, I thought about moving on, continuing to learn, and I started working in an intensive care unit (ICU). During my time in ICU, I made a drug error involving a controlled drug. Without going into too much detail, there was a lot of factors involved in this case and I was told I was going down the disciplinary route. This was a real low point for me and I felt like I really needed support, not only to come to terms with the error itself, but also support from a reflective side – what I can do, so this doesn’t happen again. I was a new band 5 nurse in the department with no previous ITU experience, with a new Band 6 and Band 7 leading the team which we were working with solidly. They chose not to suspend me, but keep me working without being able to complete medications. I continued to work as per rota, never taking a day off sick, etc. This continued for about 3 months unable to complete my job role to its full potential, and continuing the days and nights and the weekend shifts, along with personal issues of my own to contend with also. I thought at the time it was normal to feel like this post an error, but in hindsight, the support I received was not adequate. In fact, I would go as far as to say I didn’t get any support, other than the normal "are you okay" at the start of each shift. By the time the disciplinary happened, I was 'rock bottom', which is banded around a lot, but I didn’t see a way out, without my family and partner saying that I needed to get out, I don’t know what I would have done. Nevertheless, I left for new horizons, and changed my speciality. I went to A&E where I knew I wanted to be, with a great team, with great management and culture. However, one day I let them down. I completed a second drug error. This was involving an insulin/dextrose infusion for hyperkalaemia, which I mixed up for hyperglycaemia. This error rattled me again. I felt like I was going down that 'rabbit hole' yet again, becoming more and more anxious and needing extra support, more than ever. Fortunately, the patient was okay and was identified quickly. The error was serious and after talking to my manager, they suspended me from clinical duties whilst the investigation was occurring. This was absolutely devastating to me. I felt like I was just settled in my job, feeling more positive about my career that I love so much. Whilst the investigation was going on, I continued my non-clinical work, completing various tasks that would normally take an age to complete. This is where I fell in love with the non-clinical side of the department and continue to work in this area today. However, in contrast to the first incident, I was asked whether I was okay, but also followed up with regular 1:1 welfare meetings, and felt like my manager was actively supporting me. I also started a piece of work on preventing this incident happening again. I have now gone up the ladder in the same organisation, and continue to feel settled. However, this really put the importance of supporting people as one of the main priorities in my daily practice. It also put into context the real need for establishing and integrating a no blame culture and getting rid of the culture of fear. It is very easy to forget the mental health aspect. Patient safety is aimed at patients (quite rightly so), but I think somewhere in the mix, we forget about that individual who takes this home day in, day out. I understand that there is accountability and there is taking responsibility for your actions as per the Nursing & Midwifery Council (NMC) Code of Conduct. But I think we forget about humanity and the need for support and coming together when one of your team is 'down'. I can honestly say, without my team and my managers, I wouldn’t be the nurse I am today, and I am forever grateful. And those people who have done errors or know what this is like, maybe you’re going through this today; there is light at the end of the tunnel. I share my story with the upmost respect and apologies to the patients involved and also to my team!- Posted
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Content ArticleThis edited book concerns the real practice of human factors and ergonomics (HF/E), conveying the perspectives and experiences of practitioners and other stakeholders in a variety of industrial sectors, organisational settings and working contexts. The book blends literature on the nature of practice with diverse and eclectic reflections from experience in a range of contexts, from healthcare to agriculture. It explores what helps and what hinders the achievement of the core goals of human factors and ergonomics (HF/E): improved system performance and human wellbeing. The book should be of interest to current HF/E practitioners, future HF/E practitioners, allied practitioners, HF/E advocates and ambassadors, researchers, policy makers and regulators, and clients of HF/E services and products.
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Content ArticleSteven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. The term 'human factor' is rarely defined, but people often refer to reducing it. In this blog, Steven asks what are we actually reducing? In this blog, Steven questions: Are we reducing the human to ‘human error’? Are we reducing the human to a faulty information processing machine? Are we reducing the human to emotional aberrations? Are we reducing human involvement in socio-technical systems?
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Content Article
Human error: models and management
Claire Cox posted an article in Improving patient safety
In this BMJ article, James Reason discusses how the human error problem can be viewed in two ways: the person approach and the system approach. Each has its model of error causation and each model gives rise to quite different philosophies of error management. Understanding these differences has important practical implications for coping with the ever present risk of mishaps in clinical practice. Key learning points Two approaches to the problem of human fallibility exist: the person and the system approaches. The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness. The system approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects. High reliability organisations—which have less than their fair share of accidents—recognise that human variability is a force to harness in averting errors, but they work hard to focus that variability and are constantly preoccupied with the possibility of failure. -
Content ArticleIn many safety-critical environments, including healthcare, operators need to remember to perform a deferred task, which requires prospective memory. Laboratory experiments suggest that extended prospective memory retention intervals, and interruptions in those retention intervals, could impair prospective memory performance. The aim of this study, published in Human Factors journal, was to examine the effects of interruptions and retention interval on prospective memory for deferred tasks in simulated air traffic control. This can be translated into a healthcare environment.
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Content ArticleThe digital transformation of medicine is perhaps best exemplified by computerised provider order entry (CPOE), which refers to any system in which clinicians directly place orders electronically, with the orders transmitted directly to the recipient. As recently as 10 years ago, most clinician orders were handwritten. Spurred by the 2009 federal HITECH Act and the accompanying Meaningful Use program, CPOE usage rapidly increased in inpatient and outpatient settings. The vast majority of hospitals in the US and most outpatient practices now use some form of CPOE. CPOE systems were originally developed to improve the safety of medication orders, but modern systems now allow electronic ordering of tests, procedures, and consultations as well. The widespread implementation of CPOE thoughout the US has benefited clinicians and patients, but it also vividly illustrates the risks and unintended consequences of digitising a fundamental healthcare process, this paper published in PSNet explains how and why.
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Content ArticleThis case study, published in Safety Science, looks at aviation to illustrate the conflict, and double-binds, created as those in high-consequence industries negotiate the fluid lines of accountability relationship boundaries. This germane example is the crash of Swissair Flight 111, near Halifax, Nova Scotia, in 1998. The paper offers dialogue to aid in understanding the influence accountability relationships have on safety, and how employee behavioural expectations shift in accordance. McCall and Prunchnicki propose that this examination will help redefine accountability boundaries that support a just culture within dynamic high-consequence industries. Key highlights from the paper Accountability relationships, as both retrospective and prospective, support just culture. Lines are fluid in accountability relationships, forcing operators to adapt to changing goals. Viewing accountability lines as rigid, increases risk and creates double-binds for operators. Clinging to retrospective accountability reinforces blaming/shaming operators for errors.
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Content ArticleThere is evidence that COVID-19 may cause long term health changes past acute symptoms, termed ‘long COVID’. This paper includes detailed cognitive assessment and questionnaire data from tens thousands of datasets, collected in collaboration with BBC2 Horizon, which align with the view that there are chronic cognitive consequences of having COVID-19. This article, published by medRxiv, is a preprint and has not been peer-reviewed. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.
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Good outcomes for surgical patients require accurate, timely and well-communicated diagnoses. In this blog, Anna Paisley, a Consultant Upper GI Surgeon, talks about the challenges to safe surgical diagnosis and shares some of the strategies available to mitigate these challenges and aid safer, more timely diagnosis. This blog has been published as part of a series for World Patient Safety Day 2024 and the theme of Improving diagnosis for patient safety. #WPSD24, World Patient Safety Day 2024, WPSD 2024. The surgical journey Safe diagnosis requires the gathering of information from multiple sources, including clinical history, examination, and laboratory and radiological tests. This information must then be distilled and interpreted to form a working diagnosis for treatment or further investigation. This process is repeated throughout all the stages of surgical care. Before surgery, an accurate diagnosis of the cause of the patient’s symptoms must be made. As the patient’s comorbidities and frailty are integral to their surgical recovery, these must also be assessed and correctly determined. Ultimately, selection of the correct operation for the patient is only possible if a correct pre-operative diagnosis and assessment has been made. During surgery, the constantly changing information from surgical findings and from the patient’s response to surgery must be recognised, assessed and promptly processed to direct the ongoing operation and to determine the best course of action. Surgical injury or other complications also need to be recognised, correctly assessed and remedied. After the surgery, deviation from the expected course of recovery and any sudden deterioration, such as sepsis, must be promptly identified to allow necessary interventions and rescue. Results of tests carried out during surgery, such as pathology from biopsies, must be followed up appropriately to ensure that the definitive diagnosis or stage of disease is properly evaluated. What are the challenges to safe surgical diagnosis? At each stage of the surgical journey a number of factors influence the safety of this complex and evolving diagnostic process. These challenges to diagnostic safety can be divided into cognitive, systemic and communication-related factors. A robust diagnostic process relies not only on the knowledge and training of surgeons but also on cognitive factors, such as bias and limitations in clinical reasoning or failures of perception, which have been linked to up to 80% of diagnostic errors in surgery.[1] The rapid, often split-second, life or limb saving decision-making typical of surgical care is most at risk of such failures of judgement and cognitive bias. The focus is often on initial pieces of evidence or readily available information rather than the more comprehensive analysis, and this can lead to diagnostic errors and omission or error in the patient’s treatment resulting in a poorer outcome. The system within which surgical care is provided can contribute to unsafe diagnosis. Poor workflow design, time constraints and staff shortages all increase the pressure for rushed, incomplete and limited evaluation of a patient’s condition. Limited access to diagnostic testing, such a radiology, or delays in test results becoming available or being acted on, all increase the risk of missed or incorrect diagnosis. Communication problems within a team is a common barrier to safe diagnosis. Failure of effective communication between healthcare professionals and with patients leads to misunderstanding about a patient’s condition and test results. Handover from one team to another, which happens frequently during surgical care, risks the loss of vital diagnostic information and potential significant patient harm. How can we improve surgical diagnostic safety? There are many strategies available to mitigate these challenges and aid safer, more timely diagnosis. The Royal College of Surgeons of Edinburgh (RCSEd) provides many resources aimed at improving surgical diagnostic safety and other aspects of patient safety. Training Surgical training must include both factual knowledge and technical skills training. Courses focussing on improved clinical reasoning and reducing bias help to enhance diagnostic accuracy. Training programmes such as NOTSS (Non-operative technical skills for surgeons) promote training in human factors to improve patient safety in the operating theatre. In addition, RCSEd's role in setting surgical standards, examinations and the activities of the Faculty of Surgical Trainers ensures that surgical training aims to equip surgeons with the skills required in practice. Investment Investment in diagnostic pathways and technologies for more accurate, rapid diagnosis, such as the implementation of diagnostic units or hubs, can help to optimise workflows and time pressures while making the most effective and safe use of the available workforce. Diagnostic units are designed to bring multidisciplinary health care professionals, diagnostic testing and some procedures together in the same unit to provide outpatient diagnosis and treatment, making the best use of resources and mix of skills in a ‘one stop’ model of care. These units can be in larger hospitals, community health clinics or stand alone. They also provide an excellent setting for peer support and professional development of the healthcare workforce. Recommended by the Richards report,[2] these units have been developed by programmes such as GIRFT (Getting It Right First Time) in specialties such as urology. Communication Communication is key in all healthcare provision and standardised methods, such as SBAR (Situation, Background, Assessment, Recommendation) , reduce the loss of information at times such as team handover. Human factors training such as NOTSS also improves team-based communication. Shared decision making, as in the ICoNS course, can maximises information exchange between patients and healthcare providers, reducing errors. Reporting systems and shared learning Appreciation of the challenges to safe diagnosis and strategies to mitigate these can only be fully realised with robust reporting systems and shared learning from any errors identified. The RCSEd’s Team-Based Quality Review Workshop provides training in significant event reviews. In striving for the best outcomes for patients, safe diagnosis is crucial. Errors in diagnosis can have devastating consequences and must be addressed with recognition of the challenges, effective learning from errors and mitigation of the major factors identified. References Kwan JL, Calder LA, Bowman CL, et al. Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada. Can J Surg. 2024 Feb 6;67(1):E58-E65. Richards M, Maskell G, Halliday K, Allen M. Diagnostics: a major priority for the NHS. Future Healthc J. 2022 Jul;9(2):133-137. Share your experience Have you been affected by a late diagnosis? Or perhaps you have insights to share on diagnostic safety through the work that you do. If you would like to write a blog or share your thoughts, experiences or resources through the hub please get in touch with our team at [email protected] or add your comments to our community forum page. -
Content ArticleThis download is the third of three chapters of a book which complements the Chartered Institute of Ergonomics and Human Factors' Healthcare Learning Pathway and is intended as a practical resource for students The book aims to provide well-founded, practical guidance to those responsible for leading and implementing human factors programmes and interventions in health and social care. Designing tasks for human performance Chapter 3 objectives and learning outcomes: To describe the human contribution to task performance. To analyse systematically the impact of human performance on key vulnerabilities in the task. To reflect critically on the impact of work system and environmental factors on human performance. To assess the relative strengths and weaknesses of interventions aimed at improving human performance.
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Content ArticleFatigue and sleep deprivation may affect healthcare professionals' skills and communication style and also may affect clinical outcomes. However, there are no current guidelines limiting the volume of deliveries and procedures performed by a single individual, or on the length of time that they can be on call. This Committee Opinion from the American College of Obstetricians and Gynecologists (ACOG) analyses research relating to fatigue and performance in healthcare professionals in order to make recommendations to doctors and managers to improve staff and patient safety. Recommendations Physicians at all stages in their careers need to be conscious of the demands placed on them professionally and personally and should balance those demands with rest to avoid excessive fatigue or overcommitment. The medical directors of outpatient units and chairs of hospital departments of obstetrics and gynaecology may consider developing call schedules and associated policies that balance the need for continuity of care and the health care providers’ need for rest. With the growing concern about the potential consequences of health care provider fatigue on patient safety, physicians should commit to evaluating the effects that fatigue has on their professional and personal lives and should demonstrate willingness to adjust workloads, work hours, and time commitments to avoid fatigue when caring for patients.
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Content ArticleThis editorial in BMJ Quality & Safety looks at the risks to patient safety posed by negative interpersonal interactions between healthcare professionals. The authors review a recent study on the subject by Linda Guo et al that revealed how and when these negative behaviours from staff may have an impact on patient outcomes and clinical performance. They highlight the huge scale of the impact of unacceptable behaviours, arguing that it is even greater than evidenced in Guo et al's research. They also highlight that there are other, largely unexplored impacts on healthcare workers, patients and their families when they are exposed to unacceptable interactions.
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Content ArticleMany people with Long Covid experience varying levels of long-term cognitive impairment, but the causes of this are not well understood. This preprint longitudinal observational study aimed to identify links between cognitive impairment and different biomarkers in people with Long Covid. The authors reported the findings of 128 prospectively studied patients who had tested positive for Covid. They looked at: lung function, physical and mental health at two months post diagnosis. blood cytokines, neuro-biomarkers and kynurenine pathway (KP) metabolites at 2-, 4-, 8- and 12-months post diagnosis. The study identified that KP metabolites were significantly associated with cognitive decline and could therefore offer a potential therapeutic target for treating cognitive impairment related to Long Covid.
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Content ArticleThis US study in The Journal of Nursing Care Quality examined the relationship between nurse-reported patient safety grades and both burnout and the nursing work environment. It found that healthcare organisations may reduce negative patient safety ratings by reducing nurse burnout and improving the work environment at an organisation-wide level.
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Content ArticleThis systematic review in the British Journal of Surgery aimed to describe types of cognitive bias in surgery, their impact on surgical performance and patient outcomes, their source, and the mitigation strategies used to reduce their effect. The authors concluded that cognitive biases have a negative impact on surgical performance and patient outcomes across all points of surgical care. This review highlights the scarcity of research investigating the sources that give rise to cognitive biases in surgery and the mitigation strategies that target these factors.
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Content ArticleThis study in the Annals of Surgery aimed to characterise errors, events and distractions in the operating theatre, and measure the technical skills of surgeons in minimally invasive surgery practice. The authors of the study implemented the use of an operating room (OR) Black Box, a multiport data capture system that identifies intraoperative errors, events and distractions. The study found that the OR Black Box identified frequent intraoperative errors and events, variation in surgeons’ technical skills and a high number of environmental distractions during elective laparoscopic operations.
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Content ArticleExpanding on his previous commentary 'What does all this safety stuff have to do with me', Dan Cohen, Patient Safety Learning's Trustee and former Chief Medical Officer at DATIX, has written this article for the hub on personal responsibility in patient safe care. In this article, Dan looks back at the Donabedian Model, a framework for measuring healthcare quality, and suggests why this might be an over simplification and why we must also look at human factors when we think about patient safety. We are humans and we can, do and will make mistakes, so we have a personal responsibility to acknowledge and address this as a contributing factor for patient safety incidents and harm. How do we begin to address our individual responsibilities? How can each of us reduce the personal risks we pose for our patients? How do we begin to address the moral imperative to recognise and then overcome any professional complacency that may interfere with our performance? Dan believes by enhancing human performance within healthcare settings this will serve as the ultimate key to improving quality and safety. Recognition by clinicians of their own tendencies toward complacency and their own vulnerabilities toward making mistakes is to encompass a mandate for personal professional commitment and improvement. If patients are harmed on the frontlines in healthcare settings, then it is on the frontlines that many of the solutions can be found and safety improvements nurtured. First recognising, and then modulating, the human factors liabilities that exist on the frontlines and overcoming the challenges of professional complacency will be necessary steppingstones towards sustained improvements in providing patient safe care. Clinicians, managers and leaders need to work collaboratively to understand and overcome the challenges that human factors pose when addressing individual performance. Further reading on the hub from Dan: Clarity and the Art of Communication for Patient Safety Late night reflections on patient safety: commentaries from the frontline (2014) Patient safe care as a moral imperative: The mandate of medical ethics Diagnostic errors and delays: why quality investigations are key Patient Safety Spotlight Interview with Dr Dan Cohen, Patient Safety Learning Trustee What does all this safety stuff have to do with me? How one professional’s arrogance led to new insights Interview with Dr Dan Cohen on human performance
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Content ArticlePotentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies. This quality improvement study from Suliburk et al., published in JAMA Network Open, analysed the incidence of human performance deficiencies during the provision of surgical care to identify opportunities to enhance patient safety. From the 5365 operations, 188 adverse events were recorded. Of these, 106 adverse events (56.4%) were due to human error, of which cognitive error accounted for 99 of 192 human performance deficiencies (51.6%). These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.
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Content ArticleThe Health and Safety Executive have taken a topic-focused approach to human factors. These topics have proven to be key issues based on research, consultation with industry and intermediaries, and inspection experience. What can I learn? Managing human failures Staffing Fatigue and shiftwork Safety critical communications Human factors in design Procedures Competence Organisational change Organisational culture Maintenance, inspection and testing
