Clinical Reasoning Errors (define)
Errors of reasoning or decision-making caused by ‘cognitive distortions’ or ‘unhelpful thinking styles’ based on inaccurate beliefs and biases. Incl. failures to elicit, synthesise, decide or act on clinical information.
8 CREs
- Anchoring
- Attribution bias
- Ascertainment bias
- Availability bias
- Confirmation bias
- Over-confidence
- Pre-mature closure
- Diagnostic momentum
Anchoring (define)
(Sticking with an initial diagnosis)
Prematurely settling on a single diagnosis based on a few salient features of initial presentation and failing to adjust to (or disregarding) new information (compounded by confirmation bias).
Confirmation bias (define)
(Looking for what you want to see)
Tendency to seek confirming evidence to support a nursing diagnosis and overlook or discount disconfirming evidence even where the latter is more persuasive/definitive.
Ascertainment bias (define)
(Seeing what you expect to see)
Stereotyping patients and allowing thinking to be shaped by prior expectations – e.g. gender bias, ageism, racism.
Availability bias
(Picking the easiest answer)
Judging the likelihood of disease by the ease with which relevant examples come to mind such that recent experiences influence the likelihood of certain diagnoses being made. Includes recent/significant case bias – a rare diagnosis that was seen recently or had a significant impact on the clinician dominates the differential.
Diagnostic momentum
(Labelling a patient)
Once a potential diagnostic label is attached to a patient it gathers increasing momentum until it is considered definite and other possibilities are excluded
Attribution bias
(Blaming the patient)
Tendency to be judgemental and overly attribute a patient’s problems to their disposition, instead of considering external/situational factors. Includes psych-out error - overlooking or minimising co-morbid conditions or overweighting the individual’s personality in the diagnosis of psychiatric conditions.
Overconfidence bias
(Too much self-belief)
Tendency to place too much faith in one’s opinion and acting on incomplete information, intuition or hunches instead of evidence.
Premature Closure
(Cutting the process short)
Accepting a diagnosis too early in the diagnostic process before all necessary information has been gathered and alternatives explored. Compounded by unpacking principle – failure to elicit all relevant information in establishing a differential diagnosis.
Consequences of CREs
Inaccurate or incomplete reasoning process –> diagnostic errors (missed, incorrect or delayed diagnoses) –> treatment errors (unnecessary, adverse, delayed or overlooked treatment options) –> poor patient outcomes (complications/disabilities, deterioration/mortality, costs).
Preventing CREs (Individual Measures)
- Meta-cognition - analysing and critiquing thinking and reflecting on past experiences to identify biases.
- Situational awareness - recognising circumstances where error is more likely to occur – e.g. heavy caseloads, critical/complex patients, rushed handovers.
- De-biasing strategies - thought processes that make decisions less susceptible to bias and error (e.g. cognitive forcing, analytical reasoning, ‘thinking aloud’)
- Decision-support resources - second opinions, feedback, CPGs/policies, closed loop communication.
- IMSAFE checklist
Preventing CREs (Organisational Measures)
- Protocols for identifying errors - e.g. trigger tools for unplanned readmissions.
- Ongoing professional development programmes - e.g. crisis resource management training.
- Promoting evidence-based practice and culture of open disclosure
- Clinical decision support systems
- Integrated handover/information systems
- Feedback via clinical audits, cognitive autopsies, MMRs, SEAs.
Causes of CREs
- Internal cognitive biases - clinician’s beliefs, values, emotions, personality, expectations and personal interests - e.g. ethnocentrism.
- External cognitive biases - professional socialisation, peer opinion, organisational culture - e.g. Western biomedical model.
- Lack of expertise - knowledge, experience or skill-proficiency.
- Internal situational factors - stress/fatigue, ill-health, interpersonal relationships.
- External situational factors - noise/interruptions, workload/multi-tasking, time pressure, resource limitations, staffing.
Principles of open disclosure
- Open and timely communication
- Acknowledgement
- Apology or expression of regret for any harm - incl. ‘I am sorry’ NOT liability, blame or speculation.
- Supporting and meeting needs of patients, families and carers.
- Supporting and meeting needs of healthcare workers.
- Integrated clinical risk management and systems improvement
- Good governance
- Confidentiality
Sentinel Event (define)
Serious clinical incidents that have (or could have) caused serious harm (physical or psychological injury) or death of patient, that is attributable to the provision (or lack thereof) of healthcare rather than the patient’s underlying condition, that could have been prevented.
Clinical risk (define)
Types of clinical errors
- Commission - committing the wrong action - i.e. performing the wrong intervention or performing the right intervention incorrectly.
- Omission - failure to take correct course of action - i.e. failure to detect a condition or provide an intervention.
Causes of clinical errors
- Execution errors - right intention but not performing an action correctly.
- Rule violation - breaching rule or policy.
- Wrong plan - wrong intention at outset, resulting in failure to achieve outcome.
Hazardous condition (define)
Any set of circumstances that increase the likelihood of serious adverse outcome - e.g. inadequate nurse-patient ratios.
10 Sentinel events
Patient suffers serious harm or death as a result of:
1. Surgery/invasive procedure on wrong site
2. Surgery/invasive procedure on wrong patient
3. Wrong surgical/invasive procedure
4. Unintended retention of foreign object
5. Haemolytic blood transfusion reaction due to ABO incompatibility
6. Suspected suicide of patient in acute psychiatric ward.
7. Medication error
8. Use of physical/mechanical restraint
9. Discharge of infant/child to unauthorised person
10. Incorrectly positioned oro/naso-gastric tube
SAC1 Reporting
Mandatory reporting for public hospitals, private licensed health care facilities
and NGOs.
- submit investigation report within 28 days of notifying PSSU
- implement and evaluate recommendations within 6months (and refer report to PSSU)
Clinical Risk Management (explain)
System and processes that aim to minimise risks and harm to patients by:
- Establish the context
- Risk analysis - identify, analyse and evaluate risks.
- Learning lessons from AEs
- Implementing prevention strategies
Root Cause Analysis
The process used to analyse an adverse event/near miss to identify the root causes.
1. What happened? - gather information, construct a timeline.
2. Why did it happen? - identify factors that contributed/caused incident, link factors to the outcome.
3. What can be done to prevent it happening again? - make and prioritise recommendations.
Does NOT include - criminal acts (suspected patient abuse), intentional unsafe acts, acts related to substance use.
