Opinion: strategies to help doctors make better decisions will reduce clinical errors, improve patient outcomes and save lives

By JJ CoughlanGerman Heart Centre and Cormac MullinsUniversity Hospital Limerick

"Medicine is a science of uncertainty and an art of probability". This quote is attributed to William Osler, the father of modem medicine. Doctors must navigate this uncertainty on a daily basis by interpreting data, analysing problems and making clinical decisions. It has been estimated that intensive care doctors make over 100 clinical decisions during their daily ward round alone. These are often made under uncertain conditions and with incomplete information. 

In order to make decisions, people often use practical methods that are not perfect but are sufficient to achieve the task at hand. Doctors are no different in this regard. These methods are called heuristics and are like using a rule of thumb or having an educated guess. We use these methods because they are more efficient and require less thought.

Unfortunately, these mental shortcuts can also increase our risk of making errors and people sometimes make decisions that are not rational. Such cognitive bias is common, even amongst experts. Two patterns of thinking have been described: System 1 is the fast, automatic, effortless and unconscious thought process we use when we are on autopilot and, in contrast, System 2 is the slow, conscious, effortful process we use when we concentrate on thinking.

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Both systems have their own respective strengths and we often use them in combination to solve problems. When doctors are starting training, they are new to many tasks and clinical situations. They must engage their System 2 thought processes in order to minimise errors. As they gain experience, tasks and problems that previously required the use of System 2 may start to be performed automatically by System 1. This can lead to impressive feats of diagnostic skill and improved performance. Unfortunately, it can also introduce more potential for heuristic thinking and cognitive bias and increase the risk of clinical error. 

Clinical error is a major issue in medicine. It means a preventable, undesired harmful effect of care, whether or not it is evident or harmful to the patient. Over 250,000 people are estimated to die every year in the United States as a result of these errors and cognitive bias has been implicated in up to 75% of errors in medicine. If we could improve medical decision making and reduce clinical error, many lives could potentially be saved each year.

Reducing error within a complex system such as a hospital is difficult. Errors can occur both at the level of the individual (active errors) and at the level of the organisation or work environment (latent errors). We must try to organise our healthcare systems to support doctors in their decision making and to nudge them towards making better decisions in order to reduce clinical error.

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It is important that we recognise that clinical errors are often the result of an accumulation of small errors rather than an individual being wrong or making a mistake. Strategies to improve an individual’s decision making and reduce active errors have included checklists, double checks and clinical algorithms. Latent error can be more challenging to identify and often relates to the design of an organisation or the systems within the organisation. "Every system is perfectly designed for the results it gets" as the old adage says. 

Many sources of latent error have been identified. Two of the most important for doctors are shift length and sleep duration. A long session of decision making can result in the deteriorating quality of decisions made by an individual. Such decision fatigue often results in the individual favouring the status quo in order to reduce their cognitive workload. For example, it has been shown that patients meeting a surgeon at the end of their work shift were 33% less likely to be scheduled for an operation. In this situation, the decision to not operate is the safer, status quo option.

As a society, we should develop strategies to support doctors and help them make better decisions

Sleep also impacts on our decision making with reductions in sleep duration resulting in riskier decision making patterns. Interns rostered to working frequent shifts of more than 24 hours have been shown to make more errors than those working shorter shifts. In a country where doctors are still routinely rostered to work onsite for over 24 hours in a row without scheduled breaks or guaranteed sleep, the potential consequences for patient safety here are obvious.

As a society, we should develop strategies to support doctors and help them make better decisions. Reducing shift lengths and ensuring healthcare workers get adequate sleep are just two of the ways we can try to reduce latent error. Adopting checklists, guidelines and embracing algorithms in our workplaces can also combat the attentional slips and memory lapses that can result in active error. If we make the decision to prioritise these objectives, we can improve patient outcomes and save lives.

Dr JJ Coughlan is a medical doctor, specialising in cardiology who is a Research Fellow at the German Heart CentreDr Cormac Mullins is a fellow in pain medicine and anaesthesiology at the Department of Anaesthesiology, Intensive Care and Pain Medicine at University Hospital Limerick

The views expressed here are those of the author and do not represent or reflect the views of RTÉ