Search the hub

In this blog for Psychology Today, Gary Klein looks at the psychological causes of diagnostic errors, arguing that being clear about the exact causes of these errors is the only way to reduce them. Drawing on physical causes of diagnostic error identified in an Institute of Medicine report in 2015, he highlights the need to go further in understanding the explanations the report offers for diagnostic errors.

Women are 50% more likely to receive a wrong initial diagnosis; when they are having a heart attack, such mistakes can be fatal. People who are initially misdiagnosed have a 70% higher risk of dying. The latest studies have similarly shown that women have worse outcomes for heart operations such as valve replacements and peripheral revascularisation. As well as being misdiagnosed, women are less likely to be treated quickly, less likely to get the best surgical treatment and less likely to be discharged with the optimum set of drugs. None of this is excusable, but is it understandable? What is behind this bias and how can how it be fixed? Sian Harding, emeritus professor of cardiac pharmacology at Imperial College London, looks at the evidence in this Guardian article. Related reading Dangerous exclusions: The risk to patient safety of sex and gender bias Gender bias: A threat to women’s health Medicines, research and female hormones: a dangerous knowledge gap

A handful of immunologists are pushing the field to take attributes such as sex chromosomes, sex hormones, and reproductive tissues into account. Sabra Klein is deeply aware that sex matters. During her PhD research at Johns Hopkins University, Klein learned how sex hormones can influence the brain and behaviour. “I naively thought: Everybody knows hormones can affect lots of physiological processes—our metabolism, our heart, our bone density. It must be affecting the immune system,” she says. But when she graduated in 1998, she struggled to convince others that sex differences in the immune system were a worthy topic for her postdoctoral research. She ultimately found a postdoctoral position in the lab of one of her thesis committee members. And in the years since, as she has established a lab of her own at the university’s Bloomberg School of Public Health, she has painstakingly made the case that sex—defined by biological attributes such as our sex chromosomes, sex hormones, and reproductive tissues—really does influence immune responses. Through her research, Klein has helped spearhead a shift in immunology, a field that long thought sex differences didn’t matter. Historically, most trials enrolled only males, resulting in uncounted—and likely uncountable—consequences for public health and medicine. The practice has, for example, caused women to be denied a potentially lifesaving HIV therapy and left them likely to endure worse side effects from drugs and vaccines when given the same dose as men. Men and women don’t experience infectious or autoimmune diseases in the same way. Women are nine times more likely to get lupus than men, and they have been hospitalized at higher rates for some flu strains. Meanwhile, men are significantly more likely to get tuberculosis and to die of Covid-19 than women. Further reading Medicines, research and female hormones: a dangerous knowledge gap Gender bias: A threat to women’s health

When Joe Fassler's wife was struck by mysterious, debilitating symptoms, their trip to the ER revealed the sexism inherent in emergency treatment.

“Medical gaslighting” is a controversial term that has emerged to describe a phenomenon some people – women in particular – may recognise. It refers to a patient’s feeling that their symptoms are not taken seriously, or are being misdiagnosed by healthcare professionals. When she was 37, Eleanor presented at a hospital emergency department with severe chest pain. She was diagnosed with slightly high cholesterol and sent home. Three days later, she suffered excruciating pain and was taken to hospital in an ambulance. There, she was asked if she had suffered from panic attacks and was left overnight in a cubicle, before doctors realised she was having a heart attack. She needed eight cardiac stents. “I am sure no man would be asked if they suffer from panic attacks while they’re having a heart attack,” she says. This article in the Irish Times asks why women are more likely to feel their symptoms are not being taken seriously by doctors. Further reading on the hub: ‘Women are being dismissed, disbelieved and shut out’ Gender bias: A threat to women’s health Dangerous exclusions: The risk to patient safety of sex and gender bias

In this article for the Byline Times, Consultant David Oliver analyses claims by media and political commentators about spending, waste and inefficiency in healthcare and proposes a ten point plan to restore services to their 2010 level. He looks at the following claims: “The NHS has has plenty of money pumped into it by this Government and well above inflation.” “We are funded as well, if not better than many/most systems now, so resource is not an excuse” "This Government has recruited X thousand additional nurses and Y thousand additional doctors” “We need to move towards a European style social insurance based model as those systems have better outcomes and no other country has copied the NHS” “The NHS wastes far too much money on useless, overpaid managers and people in non-jobs” “People should take more responsibility for their own health so we can become a wellness service not an illness service" The NHS is in need of root and branch reform but always resists it." Ten point plan to tackle the problems faced by the NHS Train enough staff at home to meet future workforce needs Have a proper short, medium and long term workforce plan for health and social care Treat existing staff better and more flexibly to help retention and morale Use ethical immigration policy to attract and keep key workforce groups who trained overseas or come here for lower paid but vital care work Reverse the cuts in bed capacity and invest more in capital expenditure on buildings, facilities, equipment and functioning IT Come up with a long term sustainable plan for social care funding and provision, reverse the cuts and plan for future rises in care needs Invest properly in public health and prevention policy – addressing wider determinants of preventable ill health across the life course, health inequalities and inequalities in access to healthcare and ensure that health is a key part of all public policy making Accept that this focus on prevention does involve state intervention in key areas around housing, education, food, drink, obesity, smoking and mental health. Level with the public about what can realistically be expected in terms of access, wait time, staffing and the time it will take to recover from the disruption caused by covid. Better to under promise and over deliver rather than vice versa Restore annual funding increases to the NHS to at least the historic average

 In the wake of the Covid-19 pandemic, we are all too aware of the urgent health inequalities that plague our world. But these inequalities have always been urgent: modern medicine has a colonial and racist history. Here, in an essential and searingly truthful account, Annabel Sowemimo unravels the colonial roots of modern medicine. Tackling systemic racism, hidden histories and healthcare myths, Sowemimo recounts her own experiences as a doctor, patient and activist. Divided exposes the racial biases of medicine that affect our everyday lives and provides an illuminating - and incredibly necessary - insight into how our world works, and who it works for.

This 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.

Cognition is the mental process of knowing, including awareness, perception, reasoning and judgement, and is distinct from emotion and volition. Cognitive processes include mental shortcuts, which speed up decision making. However, cognitive bias occurs when the shortcut causes inferences about other people and/or situations to be drawn in an illogical fashion. There is a tendency to display bias in judgements that are made in everyday life, indeed this is a natural element of the human psyche. Jumping to a conclusion, tunnel vision, only seeing what is expected/wanted, being influenced by the views of others, all are recognisable behaviours. However, whilst such biases may be commonplace and part of human nature, it is essential to guard against these in forensic science, where many processes require subjective evaluations and interpretations. The consequences of cognitive bias may be far-reaching; investigators may be influenced to follow a particular line of enquiry or interpretation of a finding that may be incomplete, or even wrong. Simply because there is a risk of a cognitive bias does not imply that it occurs. The problem is that as it is a subconscious bias it is unlikely that an individual will know either way and therefore it is wise that all practitioners understand the issue and take proportionate steps to mitigate against it. There are a number of categories of cognitive bias described in more detail in these guidelines: Expectation bias, also known as experimenter’s bias, where the expectation of what an individual will find affects what is actually found. Confirmation bias is closely related to expectation bias, whereby people test hypotheses by looking for confirming evidence rather than for potentially conflicting evidence. Anchoring effects or focalism are closely related to both of the above and occur when an individual relies too heavily on an initial piece of information when making subsequent judgements, which are then interpreted on the basis of the anchor. Contextual bias is where someone has other information aside from that being considered, which influences (either consciously or subconsciously) the outcome of the consideration. Role effects are where scientists identify themselves within adversarial judicial systems as part of either the prosecution or defence teams. This may introduce subconscious bias that can influence decisions, especially where some ambiguity exists. Motivational bias occurs where, for example, motivational influence on decision making results in information consistent with a favoured conclusion tending to be subject to a lower level of scrutiny than information that may support a less favoured outcome. Reconstructive effects can occur when people rely on memory rather than taking contemporaneous notes. In this case people tend subsequently to fill in gaps with what they believe should have happened, and so may be influenced by protocol requirements when recalling events some time later from memory.

ECRI's annual Top 10 list helps organisations identify imminent patient safety challenges. The 2022 edition features many first-time topics, and emphasis is on potential risks that could have the biggest impact on patient health across all care settings. The number one topic on this year’s list has been steadily growing throughout the COVID-19 pandemic and impacts patients and staff on all levels: staffing shortages. Prior to 2021, there was a growing shortage of both clinical and non-clinical staff, but the problem has grown exponentially. In early January 2022, it was estimated that 24% of US hospitals were critically understaffed, while 100 more facilitates anticipated facing critical staff shortages within the following week. The list includes diagnostic and vaccine-related errors that can impact patient outcomes. In addition, several topics on this year's list reflect challenges that have arisen as a result of the stresses associated with delivering care during a global pandemic. ECRI's top 10 list of patient safety concerns: Staffing shortages. COVID-19 effects on healthcare workers’ mental health. Bias and racism in addressing patient safety. Vaccine coverage gaps and errors. Cognitive biases and diagnostic error. Nonventilator healthcare-associated pneumonia. Human factors in operationalizing telehealth. International supply chain disruptions. Products subject to emergency use authorisation. Telemetry monitoring.

Humans have a tendency to think in particular ways that can lead to systematic deviations from making rational judgements. Here's all 188 cognitive biases in existence, grouped by how they impact our thoughts and actions. Produced by DesignHacks.co.

In the previous blog in the 'Why investigate' series, we heard from Professor Martin Langham about the error trap being an error trap in itself, and about changing our focus in investigations to look wider than simplistic ideas and models of causation. In this blog, Professor Alex Stedmon considers how we might make the wrong decision when we think it’s the right decision. Martin has now passed the blog baton onto me. There will also be others contributing in due course to continue the thought-provoking and stimulating dialogue. Martin likes to quote Greek philosophy, but I rather like these words of Oscar Wilde: “Religions die when they are proved to be true. Science is the record of dead religions” As an agnostic Human Factors person, I’m not here to preach to the converted and I’m not evangelical about the ‘religion’ of Human Factors… it’s an important part of many things but the key word here is ‘part’ – it is vital that we understand things as being more than the sum of their parts and that we consider things from a number of perspectives. So, here’s the question… how can we take in many different perspectives when we’re fundamentally not wired that way? To illustrate this, I have a bad back. I was working in the garden before Christmas and managed to ‘twang’ it during some heavy lifting. Yes, there’s a sense of irony there with me being a Human Factors/ergonomics specialist and understanding about lifting things correctly and having some knowledge of biomechanics – it just goes to show it can happen to anyone! At the time it didn’t seem too bad. It has happened before and usually after a few days it begins to recover. However, that was back in December and I still have the pain in my back. Since then I have been going over what I did, where the pain is at the moment, and why I am not recovering as quickly as before. I’ve been doing this each time my back sends a shot of pain to my brain. I was moving some logs, I twisted round, I felt the pain in my back. That is about the extent of my processing because I keep going round in circles – never quite getting to a solution. We’re now into February and it is clear that this time my back injury does not fit with my idea of how it mends itself and so I have had to start looking for other explanations. A couple of years ago my wife also had a bad back but her’s was much worse than mine. She had a bulging disc in her lower back causing extreme pain and sciatic issues. Could I have done something like that? Could I have a minor disc issue? Does it feel more like a nerve or muscular problem? I’ve also continued to be very active outside, I’ve cleared a lot of ground, pruned trees, shifted railway sleepers around the garden, sawn the sleepers to make raised beds and filled them with over 3 tonnes of soil. I’ve conveniently forgotten that this activity might have hampered my recovery, or perhaps has caused new or continued strain on my back. Put simply, my initial assumption about my back has slowly proven to be incorrect and I have had to look for other explanations for why it still aches. Another example comes from a common case I investigate for the court. Imagine you’re driving on a motorway. There is a car ahead of you in the outside lane, some way off in the distance. It looks to be behaving normally, it is pointing in the right direction and so you might reasonably assume it is moving. What happens if you then realise it has stopped and you only have moments to react? You could be caught unawares by this sudden realisation that the vehicle you thought was moving is actually a static object that you might collide with. What has happened here is that you made an assumption based on an expectation that the car would be moving (how many parked cars do we expect to see in the outside lane of a motorway?). Everything else you then processed sought to confirm this was the case (pointing in the right direction, tick, no brake lights, tick, no hazard lights, tick, no people standing by the vehicle, tick, no other vehicles stopped or signs of a collision, tick). None of those things that you’ve just mentally ticked off would give you any reason to think that the car is stationary. From a Human Factors perspective, the key point here is that you would not have started out actively looking for evidence that the car was stationary. We call this aspect of human decision-making, ‘confirmation bias’. Confirmation bias refers to a well-documented fallibility of decision-making where we make an initial judgement about something and then seek to confirm that judgement is correct before we go on to look for other explanations. But it is more serious than that. We “tend to seek (and therefore find) information that confirms the chosen hypothesis and to avoid information or tests whose outcome could disconfirm it” (Wickens, 1984). This means that we might ignore conflicting information in preference to that which fits with our idea of what is happening. When we are faced with an uncertain situation, we will try to make sense of it as best we can. We may not have a clear idea of what is actually happening and, if our initial assumption is incorrect (i.e. the evidence eventually illustrates that our interpretation was wrong), we then have to find another explanation for the situation and begin collecting new evidence to support that. So, why can’t we just try to process everything and understand things more clearly? Well, in very broad terms, those studying human performance have concluded that us poor humans have limited mental resources and that we are not able to do everything all at once. We would quickly become overwhelmed by the sheer amount of data we need to process so we have to find quick and easy ways to try and make sense of things. Through experience we develop normally useful shortcuts (we call them heuristics) in our reasoning and decision-making processes. Typically, we will process information based on our experience of similar situations that we use as a template (or ‘mental model’) for how things are likely to be. This forms the basis of much of what we then ‘expect to happen’ in the world around us. Psychologists are still arguing about whether we build up our understanding of the world from a ‘top-down’ or ‘bottom-up’ perspective. In broad terms, this means do we have a general idea of things to begin with, that we then backfill with information, or do we make sense of things by building up the blocks of our understanding? Perhaps the answer is both – in some situations we might jump to an overall idea about something (i.e. it fits the pattern of our previous experience) and in others we may need to piece together things in new ways (i.e. we may not have a coherent model stored in our brains from previous experience). A key factor in this kind of decision making is our reliance on prior expectations. Drivers do not expect vehicles to be stationary in the outside lane of a motorway and therefore may not process the information about a vehicle they see ahead of them as that kind of potential hazard. In his younger years, Martin conducted a very interesting piece of research to investigate why drivers might collide with highly visible police vehicles. The findings highlighted two things – some careful drivers failed to notice the police vehicle completely and, when the police vehicle was parked in the direction as the traffic, drivers assumed it to be moving. From these results a recommendation was made that emergency vehicles should park at an offset angle to the flow of the traffic so it is more obvious that they are not in a ‘normal’ orientation to the traffic. So how does this translate to conducting investigations? At a simple level, we should always be cautious of our initial ideas about why something happened. Or if anyone else voices a solid understanding right at the start, maybe we should take a bit of time to step-back and try to survey the landscape from the highest vantage point we can find. Incidents and issues we investigate are rarely caused by one thing. As already stated, it is vital that we understand things as being more than the sum of their parts and that we consider things from a number of perspectives. However, investigations often take reductionist approaches to simplify things. By seeking out discrete factors composed of only one or two parts (at most) it is easy to start with human error as the root cause. Any investigation is a journey into unchartered territory so don’t be afraid to take time to get your bearings; look around you, what do you see? Look at the map (or perhaps any checklists or procedures) and don’t be scared of asking for directions from the locals (i.e. people close to the incident who may have valuable and unique perspectives on the issues). All too often investigations start by making assumptions ‘to get things moving’ because we have limited resources or ‘to show progress is being made’. If that is the starting point – be careful. While there can be organisational pressures to ‘get started’ and to ‘find out’ what happened, it can be dangerous if we run off into the woods without leaving a trail of pebbles to get home again (don’t use breadcrumbs, the birds tend to eat them!). It is possible that initial ideas can trap us in cycles of confirmation bias, searching out the evidence that fits with each interpretation of events. At best, we may realise it is more complicated or our initial idea is incorrect and then require more time and resources to search out other explanations. At worst, we may not realise we’ve missed something important and could even set forth recommendations which do not really address the issue or stop it from happening again. To counter this, always try to involve multidisciplinary experts in investigations. They will be people who have domain knowledge (not just qualifications on paper). But, perhaps more importantly, always keep an open but inquiring and critical mind. Never assume anything until you have discounted everything else. Regardless of what may have happened, I always start an investigation with the words of Sherlock Holmes in my head … “when you have eliminated the impossible, whatever remains, however improbable, must be the truth”. If anything, we should seek out the most unrealistic explanations rather than the most obvious ones. We are less likely to consider the least obvious ones later on and the obvious will always remain in plain sight. Before I sign off, we’ve covered how we might misinterpret information we process, how people can fail to see even highly conspicuous police vehicles and how we are programmed to find easy and convenient ways to make sense of things. Hopefully understanding our decision making in complex investigations can help us be more critical of our thinking and more aware that sometimes we might make the wrong decision when we think it’s the right decision. Read the other blogs in this series Why investigate? Part 1 Why investigate? Part 2: Where do facts come from (mummy)? Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4 When to investigate? Part 5. How or Why. Part 6 Why investigate? Part 7 – The questions and answers Why investigate? Part 8 – Why an ‘It’s an error trap conclusion’ is an error trap Why investigate? Part 10: Fatigue – Enter the Sandman Why investigate? Part 11: We have a situation Why investigate? Part 12: Ethics in research

This guidance from the Chartered Institute of Ergonomics and Human Factors (CIEHF) is aimed at early career pharmacists, especially those in foundation pharmacist positions managing the transition from education to the workplace environment.  Support in clinical decision-making is recognised as an educational development need for early career pharmacists, making the transition from a university education where there is very little exposure to the clinical environment into the work environment. This situation is compounded by a policy landscape which puts the pharmacist in a central role for clinical management of long-term complex morbidities, making clinical decision making and taking responsibility for patient outcomes increasingly important. The guidance will also be of use to those involved in the education and mentorship of early career pharmacist.

Disparities in healthcare exist because of socioeconomic factors, structural racism and implicit bias. The panelists in this video identify the problems and discuss what solutions are in place that could improve health disparities such as medical education, more training for underrepresented minority physicians, more funding for research, and fast-tracking publication of research. Furthermore, the panelists explore how the field of dermatology and other medical specialties can address these issues.

By understanding how physicians make clinical decisions, and examining how errors due to cognitive biases occur, cognitive bias awareness training and debiasing strategies may be developed to decrease diagnostic errors and patient harm. Studies of the impact of teaching critical thinking skills have mixed results but are limited by methodological problems. The authors of this paper, published in Academic Medicine, argue that explicit instruction in metacognition in medical education, including awareness of cognitive biases, has the potential to reduce diagnostic errors and thus improve patient safety.

Human factors and ergonomics (HFE) approaches to patient safety have addressed five different domains: usability of technology; human error and its role in patient safety; the role of healthcare worker performance in patient safety; system resilience; and HFE systems approaches to patient safety. This paper from the British Medical Journal, describes specific examples of HFE-based interventions for patient safety. Studies show that HFE can be used in a variety of domains.

This 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 HF/E: improved system performance and human wellbeing.

The first edition of Handbook of Human Factors and Ergonomics in Health Care and Patient Safety took the medical and ergonomics communities by storm with in-depth coverage of human factors and ergonomics research, concepts, theories, models, methods, and interventions and how they can be applied in healthcare. Other books focus on particular human factors and ergonomics issues such as human error or design of medical devices or a specific application such as emergency medicine. This book draws on both areas to provide a compendium of human factors and ergonomics issues relevant to health care and patient safety. The second edition takes a more practical approach with coverage of methods, interventions and applications and a greater range of domains such as medication safety, surgery, anaesthesia, and infection prevention. New topics include: work schedules error recovery telemedicine workflow analysis simulation health information technology development and design patient safety management. Reflecting developments and advances in the five years since the first edition, the book explores medical technology and telemedicine and puts a special emphasis on the contributions of human factors and ergonomics to the improvement of patient safety and quality of care. In order to take patient safety to the next level, collaboration between human factors professionals and health care providers must occur. This book brings both groups closer to achieving that goal.

Sepsis can be difficult to spot or articulate. This short video by MiXiT days, a theatre company made up of people with and without learning difficulties, describes the symptoms of sepsis in song format.

Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. This moving film describes what Connor was like by his friends and family and highlights the failings that caused the avoidable death of Connor.

A blog from Dr Linda Dykes. "Bryn was my patient. He died. He may have stood a better chance of survival had I been aware of the risk of small bowel volvulus in an adult.  I produced this reflective learning resource with some colleagues - and with Bryn's widow, whom we call Fiona.  Please read it... it may help you save a life one day."

Ben Tipney and Vikki Howarths' presetation on Human Factors in practice. This presentation covers: an introduction to human factors human factors training implementation of human factors in practice new initiatives.