Medical errors are an inevitable outcome of the human cognitive system working within the complex and sometimes chaotic healthcare system and perhaps this is because the modern brain is the same brain that was designed for our predecessors: Predecessors who had to hunt for the family to survive while evading the attentions of the sabre tooth tiger.
Little surprise therefore that without any firmware update human cognitive adaption has not been completely successful.
Fight or Flight
Humans still get the physical symptoms of fear that were the property of the caveman to assist in the ‘fight or flight’ decision: The sweating to aid cooling, raised heart-rate for oxygenation, dilation of the pupils for increased vision and the visceral response to make the body lighter for increased speed.
These same physical responses are alive and kicking in most patients when they visit their hospital!
So why has the adaption of human cognition systems been inadequate for the demands of the healthcare professional?
Error can be Managed
Professor James Reason explains in his illuminating books that error can never be eliminated but can be managed. In simple terms there are two distinct cognitive processes: firstly there is the conscious cognitive process which is used when a task is new or novel and secondly there is an automatic cognitive process where the task has been practiced and perfected and this process occurs at a subconscious level.
The salient point is that the working memory is extremely capacity limited. It is also very effortful to be using the working memory and it is the least preferred option.
Conscious cognition uses the working (short term) memory. The old adage is that only 7 ± 2 independent facts can be recalled for up to about 30 seconds within the working memory.
That being the case, when working memory is required because a task has not been perfected the limited nature of the conscious cognition mechanism is prone to making mistakes - These are known as knowledge based mistakes.
When a task has been perfected it is known as a skill which is then ‘parked’ in the long-term memory portion of our cognitive mechanism. When required the skill is subconsciously extracted from within the cognition mechanisms.
The positive aspect of this skill based behaviour is that it is automatic and does not need to use the very limited resources of the conscious mechanisms.
However the potential for error in skill based behaviour is also the potential cause of slips or lapses.
An Everyday Example
A wonderful everyday example of a task becoming a skill is the analogy of car driving. Recall the first driving lesson? The task of balancing the clutch and the accelerator while also remembering to check mirrors, select the handbrake to off and turn the steering wheel becomes all consuming and the capacity to listen to advice from the instructor is almost impossible.
However a few weeks after the driving test is passed, the task of driving becomes virtually automatic and there is capacity to tune radios, chat with passengers and attend to other cognitive processes.
However the potential for error is still evident: whereas the novice makes mistakes in navigation because of a lack of capacity the expert makes lapses by forgetting to stop at a postbox and post the letter that has been left on the passenger seat as a visible reminder!
Author: Guy Hirst
Photo by Fredy Jacob on Unsplash