Knowing/Thinking traps

All human beings make predictable and often repeated errors. James Reason describes the inter-relationship between thinking and errors as a “cognitive balance sheet” where each “entry on the asset side carries a corresponding debit”99. Many of these “transactions” occur simply because that is how human brains function, not because of moral failure or the desire to cause harm. Correspondingly, if someone imagines that error cannot happen to

95 _{Groopman 2007 – see note 62: page 150.}

96 _{Paget MA. The unity of mistakes – a phenomenological interpretation of medical work. 1988 Temple}

University Press, Philadelphia.

97 _{Paget MA. 1988 – see note 96: Foreword at page xiii, and Chapters4-6 especially.}

98 _{Paget MA. 1988 – see note 96: at page 96. Ironically, Paget died prematurely from a medical error}

only a year after that book was published. Her posthumous collection of writings is named after this conclusion: Paget M. A complex sorrow: reflections on cancer and an abbreviated life. DeVault MJ. (editor). 1993 Temple University Press, Philadelphia. In that she states: “Strangely, my knowledge of error has helped me deal with the errors in my care. Had I not known about the prevalence of error in medicine I would not have been able to process what has happened to me without bitterness. But I had thought these matters through already, and more than once. I now live out the complex sorrow I have before described.” (page 20).

102 them100 and that perfect performance is a reasonable expectation101, it is difficult to prevent errors or to put up barriers to stop harm. The risks of human error are compounded, where the person has multiple things on their mind, as occurs with busy doctors and other health professionals in chaotic or high stress clinical settings.

Once the ubiquity of human error is recognised, it is tempting to think that errors simply occur randomly, and that it is amazing that healthcare-related harm doesn’t occur even more often. However, the science of human error has shown that:

Human error is neither as abundant nor as varied as its vast potential might suggest. Not only are errors much rarer than correct actions, they also tend to take a

surprisingly limited number of forms [that] appear in very similar guises across a wide range of mental activities [including] action, speech, perception, recall, recognition, judgement, problem solving, decision making, concept formation and the like.

Reason says that searching for these common forms “draws the searcher inwards to the common theoretical heartland of consciousness, attention, working memory and the vast repository of knowledge structures with which they interact”. In professions like medicine, the vast domain of medical knowledge increases the possibility of error, no matter how expert and proficient a doctor becomes. Specific problems arise, for example where experts are “unconsciously skilled”. While this is a useful way of saving working memory resources, it can also lead to predictable errors, such as “strong habit intrusion”.102 James Reason and others in the Human Error Psychology field have written extensively about the

100 _{The issue of medical hubris as a contributor to poor patient care is alluded to in a number of}

introspective articles by doctors examining these issues : see for example, Dr John. Changing the Culture of American medicine – start by removing hubris. Blog post 28 July 2013, sighted on 12 March 2016 at http://www.drjohnm.org/2013/07/changing-the-culture-of-american-medicine-start-by- removing-hubris/ . Dr John is a cardiac electrophysiologist and his blog relates to a New England Medical Journal article, which showed that in studies which had evaluated established medical practice, almost half resulted in reversal of these practices in a 10-year period.

101 _{Perfectionism was identified as one of the top 10 factors impeding disclosure of medical errors in a}

large literature review of the field: Kaldjian LC. Jones EW. Rosenthal GE. Facilitating and impeding factors for physicians’ error disclosure: A structured literature review. 2006 Joint Commission Journal on Quality and Patient Safety, volume 32(4), Figure 3, page 186.

102 _{Reason 1990 - see note 99: page 68. See also Dekker S. Patient Safety: A Human Factors Approach.}

2011 CRC Press, Boca Raton (Florida USA). “Error and expertise are two sides of the same coin”: page 43

103 common forms of human error, their likely precursors, and conditions that enhance the likelihood of both error and harm103.

Medical error occurs, in part, because doctors work in complex, stressful and sub-optimal environments. Human error psychology shows that safer healthcare requires an

understanding of the fallibility of the brain, and the creation of barriers to harm. Perfectionism, counsels of perfection in training, and denial of error in practice are

unhelpful to this goal, as is denial that doctors are affected by ordinary human responses to stress. These harm-tolerant attitudes are prevalent among doctors and other health

professionals. For example, in research comparing doctors and pilots104, one in three of the intensive care respondents did not acknowledge that they made errors, and more than half said that they found it difficult to discuss mistakes. In relation to fatigue and stress, which are known to degrade all human performance, 70% of consultant surgeons believed that “even when fatigued, I perform effectively during critical times” compared to 26% of pilots. 82% believed that “True professionals can leave personal problems behind when working”. While there were lower figures among other medical and nursing staff, the authors stated that “overall only a minority of [healthcare] respondents openly recognised the effect of stress on performance”.

A later study, which showed similar results, demonstrated the negative impact of these attitudes on potentially protective actions. Only 40% of surgeons said they would let other team members know when their workload was excessive, and only about half felt that the level of stress or tiredness should be monitored by team members105. This and related research has also shown that medical teams often operate in a steeply hierarchical manner, and junior staff are discouraged from questioning the actions of senior staff.

103 _{See eg, Reason J. The Human Contribution – Unsafe acts, accidents and heroic recoveries. 2008}

Ashgate Publishing Limited London (UK); Dekker 2011 – see note 102.

104 _{Sexton et al. 2000- see note 72.}

105 _{Flin R. Yule S. McKenzie L. Paterson-Brown. Maran N. Attitudes to teamwork and safety in the}

operating theatre. 2006 Surgeon – The Royal College of Surgeons of Edinburgh and Ireland, olume 4(3), pages 145-151.

104 These characteristics are all likely to foster an error- and harm-tolerant environment, where “individuals will place themselves in error inducing conditions” that reduce “the ability of team members to manage both threats and errors in a team environment”.106 This differs from pilots, who are trained to be aware of their own feelings of fatigue and to

communicate this with their flight crew. This ensures that safety strategies are put in place to alleviate their fatigue and to have someone else checking, because of the effect of fatigue on attention.

The beliefs that someone has about their own level of intelligence, as a fixed part of their identity, can also become a risk factor for error. If intelligence is seen as an important and stable part of identity, questioning actions and decisions can be seen as a threat to identity, and so the identification of mistakes will be avoided. People become focussed “on the trait of intelligence and on proving they have it, rather than on the process of learning and growing over time”.107 _{Unfortunately, an intelligent human brain does not appear to be}

automatically protected from many of the common human “thinking traps”.

Doctors have ample evidence that they are intelligent and that this is a highly valued characteristic for their chosen profession, as discussed in chapters 5 and 6. If mistakes are not acknowledged, then there is little opportunity to observe and learn from them, or act to prevent the harm which may flow from them. As one author said self-awareness is central to address the ordinary “blind spots” and biases that occur in human thinking:

Our greatest intellectual strengths represent liabilities when they lead us to miss something that we might otherwise have noticed. They create blind spots. If we become aware of our blind spots, we can do something about them. … Once we know about this built-in limitation, we can compensate for it. … We can’t totally eradicate them, since they are built into the system. But once we become aware of them, we can try to minimize the influence of their distortion.108

Some of these blind spots arise from very useful skills, like pattern recognition. The ability to recognise similar, but new experiences through a schema is a cognitive survival

106 _{Sexton et al. 2000 – see note 72: at page 745.}

107 _{Dweck CS. Beliefs that make smart people dumb. Chapter 2 in Sternberg RJ. (editor) Why smart} people can be so stupid 2002 Yale University Press New Haven (USA)

105 technique that has served human beings well. As noted above, it allows the human brain to conserve important but limited working memory space for other information necessary for the new situation. For medical decision-making, it is a vital first step109. Unfortunately, pattern recognition capacity also can mislead, for example through anchoring bias, that puts higher weight on the first information which comes to attention110. It may also lead to

“recognition” of a pattern when one does not exist, which is called “illusory correlation”111. The brain tends to look for information confirming its hypothesised pattern and to ignore variations (confirmation bias). There are many common blind spots which create a risk for patients by encouraging a doctor to miss something, which, with hindsight, looks

obvious.112 Another blind spot arises when doctors do not know that they do not know

109 _{Croskerry P. Achieving quality in clinical decision making: Cognitive strategies and detection of bias.}

2002 Academic Emergency Medicine. November, volume 9(11), pages 1184-1204: see especially Table 2- strategies in decision making, page 1185.

110 _{See eg, Strack F. Mussweiler T. Explaining the enigmatic anchoring effect: mechanisms of selective}

accessibility. 1997 Journal of Personality and Social Psychology, volume 73(3), pages 437-446.

111 _{See eg Hamilton DL. Gifford RK. Illusory correlation in interpersonal perception: a cognitive basis of}

stereotypic judgments. 1976 Journal of Experimental Social Psychology, volume 12(4), pages 392- 407.

112 _{Some practical examples of blind spots in medicine are:}

• focussing on a specific detail and ignoring the bigger picture, such as focussing carefully on a specific organ in an operation, and accidentally nicking a major blood vessel;

• not thinking sufficiently before acting, such as sending someone home when it is a busy night without doing a specific test, which would ensure the patient’s complaint was not an imminent threat to life;

• jumping to conclusions without seeking better information, for example assuming that a fat patient’s problems are weight related when they are not;

• simply not noticing an important piece of information or forgetting to ask, for example, a patient’s allergies, or not checking what was in the syringe before they inject a patient; • not seeing themselves and their actions as others see them, for example, when a senior doctor

provides a shaming response to a young doctor who asks a question;

• seeing everything through their own personal, doctor lens, for example, a doctor labelling a patient’s failure to take medicine as “non-compliance”, without asking the patient why they aren’t taking their medication – further inquiry might reveal issues that the doctor could address, for example, if the patient cannot open the bottle, cannot read the instructions, cannot remember when to take it, or the medicine makes them feel ill;

• using their own values and beliefs as evidence or to reinforce ambiguous evidence, for example, a regular patient who is seen as a complainer comes for a consultation outlining further non- specific symptoms and the doctor dismisses the patient without checking his or her vital signs or ordering tests, with the result that the patient’s cancer remains undiagnosed until too late.

106 something and assume they do113. There are ways to tackle these and other blind spots and to reduce their potential for negative impact on patients. However, to put in place barriers to address blind spots requires a recognition that they exist and can impact on practice.114 The feeling of “knowing” and of “being certain” involve other processes of the mind, which can give rise to medical errors and preventable patient harm, or to mistaken “knowledge” about events. While the issue of uncertainty provides a fertile ground for alternative explanations for preventable patient harm, absolute and unquestioning certainty can also provide a strong defence of identity. In this case, no alternative explanation is necessary, because the person “knows” what they did was right. The processes of laying down memory and the brain’s construction of “knowing” can, in fact, mislead someone about what, in fact, happened. This is particularly so when alternative explanations of events may give rise to threats to identity. The incontrovertible understanding of an event that is “known” with certainty may, in fact, be a creation of the brain itself, rather than observable facts.

A study of students’ recollections of what they were doing when they first heard of the Challenger space shuttle disaster compared an immediate post event diary record (recorded the following day) with a recollection two and a half years after115. Only 25% of the students who participated in the second questionnaire even recalled having completed the survey immediately after the disaster116. Despite this being the kind of “flash bulb” memory that people would be expected to clearly recollect, the two records were quite different for the majority of the students who participated. The accuracy of the subsequent recollection had a mean score of only 2.95, when 7 was a perfect match117. 7% of students

113 _{This is called the Dunning-Kruger Effect eg. Hodges B. Regehr G. Martin D. Difficulties in}

recognising one’ own incompetence: novice physicians who are unskilled and unaware of it. 2001

Academic Medicine. October, volume 76(10 Supplement), s87-89.

114 _{Van Hecke ML. 2007 – see note 108. This book sets out a range of common “blind spots” with}

strategies for how these can be tackled to reduce their incidence and to allow understanding of how they arise.

115 _{Neisser U. Harsch N. Phantom Flashbulbs: False recollections of hearing news about Challenger.}

Chapter in Winograd E. Neisser U. (editors) Affect and Accuracy in Recall: Studies of “Flashbulb” Memories. 1992 Emory Symposia on Cognition, Cambridge University Press, New York: pages 9-31.

116 _{Neisser et al. 1992 – see note 115: page 14.} 117 _{Neisser et al. 1992 – see note 115: page 18.}

107 had a 7 score. 25% were wrong about everything and 50% scored 2 or less. Perhaps the most interesting result was that there was no significant correlation between the accuracy of their recall and their certainty of its accuracy at the time of recall. When they saw their conflicting responses, many still only “remembered” their false recollection and had no memory of the event as recorded at the time.118.

Hindsight bias is another example of this kind of response. Hindsight bias has a complicated role in relation to error. People who are involved can recast the events to avoid an identity-threatening dissonance 119, which can result in very different “factual” stories about an incident. This is not because any of these people are lying and seeking to deceive, – rather their subconscious mind has either selectively remembered or even altered facts120_{. This bias also affects those who are looking at an incident, once they have an}

outcome to consider. James Reason warns that:

Being blessed with both uninvolvement and hindsight it is a great temptation for retrospective observers to slip into a censorious frame of mind and to wonder how these people could have been so blind, stupid, ignorant or reckless. … The

perceptual biases and strong-but-wrong beliefs that make incipient disasters so hard to detect by those on the spot also make it difficult for accident analysts to be truly wise after the event. Unless we appreciate the potency of these retroactive

distortions, we will never truly understand the realities of the past, nor learn the appropriate remedial lessons.121

Mortality and Morbidity Committees and many Risk Management investigations are examples of these kind of retrospective, simplification processes. The complexity of the actual event may be ignored in the hunt for a responsible person. Rather than an effort to tease out complexity to learn from mistakes, the process can become a ‘blame and shame’ process for all concerned, with simplified presentations of right and wrong. These pay little attention to the environmental and personal complexities that exist around most instances of preventable patient harm. Alternatively, they can become exculpatory forgiveness or responsibility avoidance processes. Neither of these are effective ways of “learning from

118 _{Neisser et al. 1992 – see note 115: pages 21 and 25-26.}

119 _{An excellent example of this is provided in the following editorial by the Chair of the Australian}

Patient Safety Foundation, Professor Bill Runciman. Runciman WB. Complete Retrograde Dysmnesia. 1995 Journal of Clinical Monitoring, January, volume 11(1), pages 3-4.

120 _{Fine 2005 – see note 70: “The Deluded brain – a slapdash approach to the truth”: pages 59-85.} 121 _{Reason J. 1990 – see note 102: at pages 214-215.}

108 mistakes” by examining what happened. Both processes and outcomes will discourage the recognition of errors as part of everyday reflection on practice.

In Caplan, Posner and Chaney’s classic 1991 study on hindsight bias122, they looked at whether outcome affected judgments about the quality of care in peer review based on an implicit standard of care. 1500 closed claims cases were drawn from 22 malpractice insurers, and were included in the study where there was either a temporary or permanent injury, the outcome of which could readily be changed and where there was no gross error or obvious breach of clinical management. The 21 cases that fulfilled these criteria were then made into 2 matched sets, with only the outcomes changed. Changes were between a permanent injury and a temporary one. Doctors were asked to determine whether the care was appropriate, whether it was less than appropriate or whether it was impossible to tell. When a temporary injury was changed to a permanent one, the decision about care being appropriate decreased by 31%, while less than appropriate care increased by 14% and “impossible to judge” went up by 17%. When the movement was the other way, (outcome from permanent to temporary harm), the appropriate care rating increased by 28%, less than appropriate care decreased by 12% and “impossible to judge” decreased by 16%. While this study clearly shows the impact of hindsight bias, it also confirms the defensive or