Medical Errors Flashcards
Define: Intrinsic Errors
Errors occurring within the attending physician or veterinarian’s immediate sphere of influence and do involve his or her clinical reasoning process
Define: Systemic Errors
Errors in the delivery of health care
The failure of a planned health care intervention to be completed as intended
The plan was fine, but it was not executed properly
What are common factors that lead to intrinsic errors?
Time pressure
Overconfidence
Faulty/incomplete data gathering
Knowledge gap or inexperience
Physical factors (fatigue, illness)
Conscious/unconscious bias
What are examples of systemic errors?
Wrong-site surgery
Failure of the clinician to recognize pt allergies
Miscommunication
Mislabeling medication
Improper rate of fluid administration
Equipment failure
Premature Closure
Concluding evidence gathering and making a diagnosis prior to thorough reflection on all the data. The error is commonly associated with pattern recognition.
False Consensus
This is a form of premature closure. You offer limited analysis and/or information because you believe that others have reached an identical conclusion.
Confirmatory Bias
The tendency to seek or favor data that confirms one’s preferred diagnosis while ignoring or disregarding data that would disfavor the diagnosis.
Unintentional Sequestration of Data
Pertinent information is unintentionally omitted by someone on the team, e.g., clinical sign, previous medical history, etc.
Illusory Transactive Memory System
In a medical setting, an illusory (illusion‐based) transactive memory system provides the medical team with a deceptive sense of security that because you’re working with a team, someone before you got all the data that you need. In other words, “Someone must have read the chart.”
Contagious Illusion
Respect for authority or desire for consensus allows data to be interpreted as valid by others, e.g., a supervising clinician states that a collection of clinical signs means the patient has [x] disease.
Selective Perception
Expectations influence your senses such that you can feel, hear or see something that you expect to hear.
Primary Effect
Initial events in the patient’s medical history or disease are weighted more heavily that events that occur later.
Recency Effect
The most recent events in the patient’s medical history or disease are more heavily the events that occurred earlier.
Availability Heuristic
Estimating what is more likely by what is most available in your memory, which is inherently biased toward vivid, unusual, or emotionally charged examples.
Heuristic is the process of figuring something out on your own; obviously, since our memories are unique to each of us, the availability heuristic tends to bias each of us toward things that tend to come to mind easily…which again, tend to be biased
toward vivid / unique / unusual examples
Your patient has been referred for cardiac disease. On auscultation you hear a faint murmur even though there isn’t one. Which clinical reasoning error is being committed?
Selective perception
