Cognitive error not a dead letter

Ruth Ryan ruth at RYAN-GRAHAM.COM
Tue Aug 6 12:58:42 UTC 2019

We don't pay so much attention to diagnostic error in surgery, but if we did, what would we find?
Here is a JAMA study of human performance errors (not just diagnostic) in the OR setting.

Interestingly, of all the causes looked for in human performance (execution, planning, communication, teamwork and violating rules), cognitive error presented as foundational to more than half.

Suliburk JW, Buck QM, Pirko CJ, et al. Analysis of Human Performance Deficiencies Associated With Surgical Adverse Events. JAMA Netw Open. Published online July 31, 20192(7):e198067. doi:10.1001/jamanetworkopen.2019.8067
"Among these 106 HPD adverse events, a total of 192 HPDs (mean [SD], 1.8 [0.9] HPDs per HPD event) were identified. Human performance deficiencies were categorized as execution (98 HPDs [51.0%]), planning or problem solving (55 HPDs [28.6%]), communication (24 HPDs [12.5%]), teamwork (9 HPDs [4.7%]), and rules violation (6 HPDs [3.1%]). Human performance deficiencies most commonly presented as cognitive errors in execution of care or in case planning or problem solving (99 of 192 HPDs [51.6%]). In contrast, technical execution errors without other associated HPDs were observed in 20 of 192 HPDs (10.4%)."

Ruth Ryan

Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

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