Improving clinical communication: a view from psychology.
Recent research has studied the communication behaviors of clinical hospital workers and observed a tendency for these workers to use communication behaviors that were often inefficient. Workers were observed to favor synchronous forms of communication, such as telephone calls and chance face-to-face meetings with colleagues, even when these channels were not effective. Synchronous communication also contributes to a highly interruptive working environment, increasing the potential for clinical errors to be made. This paper reviews these findings from a cognitive psychological perspective, focusing on current understandings of how human memory functions and on the potential consequences of interruptions on the ability to work effectively. It concludes by discussing possible communication technology interventions that could be introduced to improve the clinical communication environment and suggests directions for future research. (+info)
Methods of cognitive analysis to support the design and evaluation of biomedical systems: the case of clinical practice guidelines.
This article provides a theoretical and methodological framework for the use of cognitive analysis to support the representation of biomedical knowledge and the design of clinical systems, using clinical-practice guidelines (CPGs) as an example. We propose that propositional and semantic analyses, when used as part of the system-development process, can improve the validity, usability, and comprehension of the resulting biomedical applications. The framework we propose is based on a large body of research on the study of how people mentally represent information and subsequently use it for problem solving. This research encompasses many areas of psychology, but the more important ones are the study of memory and the study of comprehension. Of particular relevance is research devoted to investigating the comprehension and memory of language, expressed verbally or in text. In addition, research on how contextual variables affect performance is informative because these psychological processes are influenced by situational variables (e.g., setting, culture). One important factor limiting the acceptance and use of clinical-practice guidelines (CPGs) may be the mismatch between a guideline's recommended actions and the physician-user's mental models of what seems appropriate in a given case. Furthermore, CPGs can be semantically complex, often composed of elaborate collections of prescribed procedures with logical gaps or contradictions that can promote ambiguity and hence frustration on the part of those who attempt to use them. An improved understanding of the semantics and structure of CPGs may help to improve such matching, and ultimately the comprehensibility and usability of CPGs. Cognitive methods of analysis can help guideline designers and system builders throughout the development process, from the conceptual design of a computer-based system to its implementation phases. By studying how guideline creators and developers represent guidelines, both mentally and in text, and how end-users understand and make decisions with such guidelines, we can inform the development of technologies that seek to improve the match between the representations of experts and practitioners. We urge informaticians to recognize the potential relevance of cognitive analysis methods and to begin more extensive experimentation with the their use in biomedical informatics research. (+info)
Analysis of complex decision-making processes in health care: cognitive approaches to health informatics.
Decision making by health care professionals is often complicated by the need to integrate ill-structured, uncertain, and potentially conflicting information from various sources. In this paper cognitive approaches to the study of decision making are presented within the context of a variety of complex health care applications. In recent years it has become increasingly accepted that in order to build information systems that can support complex decision making it will be necessary to more fully understand human decision-making processes. Methodological approaches are described that aim to explicate the decision making and reasoning skills of subjects as they perform activities involving the processing of complex information. The paper begins by presenting the theoretical foundations for cognitive analyses of decision making, including discussion of major approaches to the study of decision making in a range of real-world domains, including medicine. Applications of cognitive approaches are then illustrated, including a description of a study in which subjects were asked to "think aloud" in providing treatment decisions for complex medical cases. The resulting protocols were then analyzed for subjects' use of decision strategies and problems in reasoning. Extension of cognitive approaches to the study of group decision-making processes is also described. Recent approaches are discussed which borrow from advances in the study of human-computer interaction and which utilize video analysis of decision-making activities involving information technologies. Using these approaches it has been found that health care information systems, such as computerized patient record systems, may have inadvertent effects on human decision making. Implications of a cognitive approach to improving our understanding of complex decision making are discussed in the context of developing appropriate computer-based decision support for both individuals and groups. (+info)
Medical error: is the solution medical or cognitive?
Is the solution for medical errors medical or cognitive? In this AMIA2001 panel on medical error, we argued that medical error is primarily an issue for cognitive science and engineering, not for medicine, although the knowledge of the practice of medicine is essential for the research and prevention of medical errors. The three panelists presented studies that demonstrate that cognitive research is the foundation for theories of medical errors and interventions of error reductions. (+info)
Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective.
OBJECTIVE: To apply human performance concepts in an attempt to understand the causes of and prevent laparoscopic bile duct injury. SUMMARY BACKGROUND DATA: Powerful conceptual advances have been made in understanding the nature and limits of human performance. Applying these findings in high-risk activities, such as commercial aviation, has allowed the work environment to be restructured to substantially reduce human error. METHODS: The authors analyzed 252 laparoscopic bile duct injuries according to the principles of the cognitive science of visual perception, judgment, and human error. The injury distribution was class I, 7%; class II, 22%; class III, 61%; and class IV, 10%. The data included operative radiographs, clinical records, and 22 videotapes of original operations. RESULTS: The primary cause of error in 97% of cases was a visual perceptual illusion. Faults in technical skill were present in only 3% of injuries. Knowledge and judgment errors were contributory but not primary. Sixty-four injuries (25%) were recognized at the index operation; the surgeon identified the problem early enough to limit the injury in only 15 (6%). In class III injuries the common duct, erroneously believed to be the cystic duct, was deliberately cut. This stemmed from an illusion of object form due to a specific uncommon configuration of the structures and the heuristic nature (unconscious assumptions) of human visual perception. The videotapes showed the persuasiveness of the illusion, and many operative reports described the operation as routine. Class II injuries resulted from a dissection too close to the common hepatic duct. Fundamentally an illusion, it was contributed to in some instances by working too deep in the triangle of Calot. CONCLUSIONS: These data show that errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. The misperception was so compelling that in most cases the surgeon did not recognize a problem. Even when irregularities were identified, corrective feedback did not occur, which is characteristic of human thinking under firmly held assumptions. These findings illustrate the complexity of human error in surgery while simultaneously providing insights. They demonstrate that automatically attributing technical complications to behavioral factors that rely on the assumption of control is likely to be wrong. Finally, this study shows that there are only a few points within laparoscopic cholecystectomy where the complication-causing errors occur, which suggests that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury. (+info)
Collaborative e-learning using streaming video and asynchronous discussion boards to teach the cognitive foundation of medical interviewing: a case study.
BACKGROUND: Advances in electronic technology have created opportunities for new instructional designs of medical curricula. OBJECTIVE: We created and evaluated a 4-week online elective course for medical students to teach the cognitive basis for interviewing skills. METHODS: Ten students, from 2 medical schools, studied online modules on interviewing concepts and viewed videos illustrating the concepts. They then participated in asynchronous discussion groups designed to reinforce course concepts, stimulate reflective learning, and promote peer learning. RESULTS: In qualitative evaluations, learners reported improvements in self-awareness; increased understanding of interviewing concepts; and benefits of online learning vs face to face learning. Participants reported high levels of satisfaction with online learning and with achievement of course objectives. Self-reported knowledge scores increased significantly from pre-course completion to post-course completion. CONCLUSIONS: Online education has significant potential to augment curriculum on the medical interview, particularly among students trained in community settings geographically distant from their academic medical center. (+info)
A cognitive taxonomy of medical errors.
OBJECTIVE: Propose a cognitive taxonomy of medical errors at the level of individuals and their interactions with technology. DESIGN: Use cognitive theories of human error and human action to develop the theoretical foundations of the taxonomy, develop the structure of the taxonomy, populate the taxonomy with examples of medical error cases, identify cognitive mechanisms for each category of medical error under the taxonomy, and apply the taxonomy to practical problems. MEASUREMENTS: Four criteria were used to evaluate the cognitive taxonomy. The taxonomy should be able (1) to categorize major types of errors at the individual level along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to describe how and explain why a specific error occurs, and (4) to generate intervention strategies for each type of error. RESULTS: The proposed cognitive taxonomy largely satisfies the four criteria at a theoretical and conceptual level. CONCLUSION: Theoretically, the proposed cognitive taxonomy provides a method to systematically categorize medical errors at the individual level along cognitive dimensions, leads to a better understanding of the underlying cognitive mechanisms of medical errors, and provides a framework that can guide future studies on medical errors. Practically, it provides guidelines for the development of cognitive interventions to decrease medical errors and foundation for the development of medical error reporting system that not only categorizes errors but also identifies problems and helps to generate solutions. To validate this model empirically, we will next be performing systematic experimental studies. (+info)
Designing the design phase of critical care devices: a cognitive approach.
In this study, we show how medical devices used for patient care can be made safer if various cognitive factors involved in patient management are taken into consideration during the design phase. The objective of this paper is to describe a methodology for obtaining insights into patient safety features--derived from investigations of institutional decision making--that could be incorporated into medical devices by their designers. The design cycle of a product, be it a medical device, software, or any kind of equipment, is similar in concept, and course. Through a series of steps we obtained information related to medical errors and patient safety. These were then utilized to customize the generic device design cycle in ways that would improve the production of critical care devices. First, we provided individuals with different levels of expertise in the clinical, administrative, and engineering domains of a large hospital setting with hypothetical clinical scenarios, each of which described a medical error event involving health professionals and medical devices. Then, we asked our subjects to "think-aloud" as they read through each scenario. Using a set of questions as probes, we then asked our subjects to identify key errors and attribute them to various players. We recorded and transcribed the responses and conducted a cognitive task analysis of each scenario to identify different entities as "constant," "partially modifiable," or "modifiable." We compared our subjects' responses to the results of the task analysis and then mapped them to the modifiable entities. Lastly, we coded the relationships of these entities to the errors in medical devices. We propose that the incorporation of these modifiable entities into the device design cycle could improve the device end product for better patient safety management. (+info)