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Emily Merrill, PhD, APRN, FNP BC, CNE, FAANPMelanie Richburg, DNP, FNP-CBarbara Cherry, DNSc, MBA, RN, NEA-BC

Reduc ingCogni t i ve Errors: ImprovingHeal thCare throughBe tte r Thinking

Making clinical decisions is part of your everyday professional role…and can be riskyDiagnostic thinking errors are a chief cause of preventable morbidity and mortalityCare and safety can be improved by understanding “thinking processes”

“Where do bad decisions come from? Mostly from distortions and biases—a whole series of mental flaws—that sabotage our reasoning” (Hammond, Keeney, & Raiffa, 2003, p. 1)

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Youdoi t e ve ryday

Explore the role of cognitive errors as a prominent cause of preventable morbidity and mortality.Identify common cognitive errors in health care.Discuss strategies to reduce cognitive errors and improve clinical reasoning and decision-making.

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Se ssionObje c t ive s

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Common cognitive errorsAnchoringStatus QuoConfirming evidenceAffective biasSatisfaction of searchFramingDiagnosis momentumSatisfaction of searchDisregard of uncertaintyPrototype situations/cases

Se ssionObje c t ive s

Initial impressions anchor subsequent thoughts and judgementsLock onto patient’s initial presentation and fail to adjust the initial impression when new information is foundDisproportionate weight is given to the first information received

Past event or trend (most common use of anchoring)

Comments by colleagues; recent news item

Quickly latch on to a single answer(Balogh et al, 2015; Hammond, Keeney, & Raiffa, 2003)

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Anchoring

People have a strong bias towards maintaining status-quoRepresents a safer course and less riskCommission bias vs omission biasBreaking from the status-quo requires actionStatus-quo may be the best choice, but not because it is most comfortable

(Hammond, Keeney, & Raiffa, 2003)

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Status-Quo

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Seeking information to support your existing view or instinctAvoiding information that contradicts your view or instinct, which affects how you collect and interpret evidencePeople are drawn to information supporting their subconscious thoughts

(Hammond, Keeney, & Raiffa, 2003)

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Confi rmingEvidence

Affective biasClinician’s emotions, feelings and biases affect judgement

FramingFrame patients such as a “case of diabetes and renal failure”

AvailabilityTendency to judge the likelihood on an event by the ease with which relevant examples come to mind

Diagnosis momentumOnce a particular diagnosis becomes fixed in a clinician’s mind (despite incomplete evidence), the diagnosis is passed on to peers who accept it without question

(Balogh et al, 2015; Groopman, 2007)

Othe r CommonCogni t i ve Errors

Prototype situations/casesClinicians establish “prototype” cases in their minds and then have a natural tendency to zero in on certain characteristics of a case/situation and make it fit the prototype

Disregard of uncertaintyDo not acknowledge the uncertainty inherent in clinical practice and have a proclivity to substitute certainty for uncertainty

Culture of conformity and orthodoxyInherent in the apprentice process which leads clinicians to treat certain conditions depending on where/how they trained

Satisfaction of search or premature closureTendency to stop searching for an answer once you find something

(Balogh et al, 2015; Groopman, 2007)

Othe r CommonCogni t i ve Errors

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View a problem from different perspectives

Think through the issue on your own before consulting others; do not ask leading questions when consulting others

Seek information from a range of individuals

Avoid anchoring others

Determine if you are looking at all evidence with equal rigor

Do not accept confirming evidence without question

Ask a colleague to play devil’s advocate

Be honest: is the evidence supporting a smart decision, or just what you want to do?

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S tr ateg ies toImproveDecis ionMak ing

Interprofessional team input is critical including radiologists and pathologists

Always generate a short list of alternatives – no matter sure you are of your decision

Always reflect rather than tacitly act on scant precedent

Always keep uncertainties in mind and acknowledge

Use creativity and imagination where the data and clinical findings do not all fit neatly together

Ask questions: What else could it be? Could it be more than one problem?.

(Balogh et al, 2015; Groopman, 2007; Hammond et al, 2003)

S tr ateg ies toImproveDecis ionMak ing

32 year old female

Chief Complaint: Epigastric pain x 2 days

Denied nausea, vomiting, diarrhea, or bowel changes

Epigastric pain worsened with food intake

No urinary frequency, urgency, or dysuria/no fever

8 weeks pregnant/ OB-GYN visit earlier same day; visit WNL

No vaginal bleeding

Epigastric tenderness

CaseS tudy #1

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What biases were present?

What context error occurred?

CaseS tudy #1

47 year old male with DM, bilateral BKA with delayed wound healing

He and his wife were distressed; difficult, dissatisfied

Lived long distance from clinic/ED

Chief Complaint: Vomiting x 3; unable to eat

Two recent ED visits within last 4 days

Visit #1: treated with Zofran

Visit #2: treated for H. Pylori

Denied abdominal pain, fever, diarrhea

CaseS tudy #2

Do difficult patient impeded accurate diagnoses?

Diagnostic accuracy declines significantly when clinicians face “difficult patients” (those who engage in disruptive behaviors)

Study synopsis: 6 different scenarios of patient behavior:

Frequent demanding

Aggressive

Questioned the physician’s competence

Ignored the physician’s advice

Had low expectations

Presented himself as completely helpless (Barclay, 2016)

Difficult Patients-Accur ateDiagnoses?

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Develop awareness and insight

Get more information

Always consider alternatives

Metacognition (Step back and reflect: use system 1 and 2)

To improve patient safety and facilitate better care, all providers should perform personal inventory:

Am I rushing to finish on time?Have I had a prior negative experience with patient?Am I tired?Has the diagnosis been suggested by family or family?

(Klocko, 2016)

CognitiveDebias ing Techniques

Balogh, E.P., Miller, B.T., & Ball, J.R. (Eds). (2015). Improving diagnosis in health care. Institute of Medicine. Retrieved July 26, 2017 from http://www.nap.edu/download/21794

Barclay, Laurie. (2016). Do difficult patient impede accurate diagnoses? Medscape. Retrieved May, 10, 2016 from http://www.medscape.org/viewarticle/861176?nlid

Groopman, J. (2007). How doctors think. New York: Houghton Mifflin Company.

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Re fe rence sandRe source s

Hammond, J.S., Keeney, R.L., & Raiffa, H. (2003). The hidden traps in decision making. Harvard Business Review. Retrieved December 17, 2015 from http://sciencepolicy.colorado.edu/students/envs_5120/hammond_1998.pdf

Klocko, D.J. (2016). Are cognitive biases influencing your clinical decisions? Clinical Reviews. Retrieved July 20, 2016 fromhttp://www.clinicianreviews.com/cecme/cecme-activities/article/are-cognitive-biases-influencing-your-clinical-decisions/3217c08c928e5192acc6e97865a 4cd0d.html

Re fe rence sandRe source s

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