Flashcards in Medical Decision Making Deck (29):
Diagnosis is missed or delayed in how many % of acute hospital admissions?
How many % of patients don't receive evidence-based care?
Up to 45%
How many investigations and drugs administered are potentially unnecessary?
Almost half of errors involved reasoning or decision quality - what does this include?
Failure to elicit, synthesise, decide or act on clinical information
What is the trouble with things going wrong?
The mistake is not always admitted to
Why might mistakes not be reported? (5)
Staff didn’t know what to report or why
Patient was ‘unharmed’
Staff felt too busy to report
Lack of feedback when errors were reported
Fear of disciplinary action or litigation
What is the person approach (explanatory model of human error)?
Healthcare professional is responsible. These are known as active errors, e.g. forgetfulness, negligence, poor motivation, carelessness, inattention
What are the weaknesses of the person approach? (3)
Prevents analysis of what went wrong (no opportunity to change/improve)
Failure to recognise patterns of mistakes
Suggests mistakes are only made by bad doctors
What is the systems approach (explanatory model of human error)?
This assumes that mistakes are inevitable because humans are fallible. Errors are consequences of unworkable procedures, inadequate equipment, fatigue, understaffing etc, rather than causes. This suggests the best way to prevent errors is to create a system which defends against human error.
Explain the model of inductive clinical reasoning.
Initial collection of information from history/exam -> a series of logical problem solving steps -> diagnosis
Explain the hypothetico-deductive model.
Collection of info from history/exam -> generate hypothesis -> analyse info to confirm/refute hypothesis -> diagnosis
What is pattern recognition? What are the benefits?
It is a quick, often intuitive process based on experience of lots and lots of cases. This means that atypical presentations can still be spotted and that the experienced doctor will know what additional information is needed to complete the clinical picture.
What are heuristics?
Cognitive shortcuts /decisional shortcuts e.g. rule of thumb, educated guess, common sense
What are cognitive biases?
Systematic and predictable errors in judgement, resulting from reliance on heuristics. They are cognitive dispositions to respond in various ways in certain situations (over 30 have been identified).
Give some examples of cognitive biases. (6)
Fundamental Attribution Error
What is meant by availability (cognitive bias)?
Things seem more likely if they readily come to mind, so a disease seen recently will seem more likely or over-diagnosing rare conditions because they are more memorable.
What is meant by representativeness (cognitive bias)?
Diagnosis seems more likely based on how similar the characteristics are to typical cases. This only looks for prototypical manifestations of disease.
What is meant by anchoring (cognitive bias)?
Perceived probability of event or diagnosis based on one trait or piece of information (e.g making a diagnosis based on a first impression).
What is meant by diagnosis momentum (cognitive bias)?
Labels become attached to patients and they get more and more attached to the person, because the staff and family use the diagnosis, so it is hard to go back and change it so all other possibilites are excluded.
What is meant by fundamental attribution error (cognitive bias)?
The tendency to blame people for their illness rather than the circumstances. This occurs particularly for psychiatric patients, minorities, those with substance abuse issues and other marginalised groups.
What is meant by commission bias (cognitive bias)?
The tendency to action rather than inaction, such as prescribing tests or medication which are not necessary. It's more common in over-confident doctors, but it’s also a function of what patients expect of medical encounters.
How can we avoid cognitive bias? (9)
Decrease reliance on memory
Make the task easier
Minimise time pressures
Establish accountability and possibility of feedback
How does responsibility differ between informed and shared decision making?
Informed - responsibility lies with patient
Shared - responsibility is shared between patient and doctor
Explain informed decision making.
The doctor gives the patient all the factual/medical information they need about treatments and the patient decides what treatment/management to have.
Explain shared decision making.
The doctor and the patient are both involved. They discuss possible treatment/management options and the doctor gives their expert opinion/recommendation, and they both decide on the treatment/management together.
Explain a doctor-centred consultation.
The doctor talks and the patient listens. The doctor makes decisions and tells the patient what to do.
Explain a patient-centred consultation.
The patient expresses their own agenda. The doctor uses active listening to understand the patient’s point-of-view. They agree on diagnosis and management together.
What are the benefits of patient-centred consultations? (3)
-Patient feels they have been heard (improves satisfaction)
-More likely to be able to prescribe a regime that the patient understands/can follow