Clinical decision making is a cornerstone of high-quality care in emergency medicine. The density of decision making is unusually high in this unique milieu, and a combination of strategies has necessarily evolved to manage the load. In addition to the traditional hypothetico-deductive method, emergency physicians use several other approaches, principal among which are heuristics. These cognitive short-cutting strategies are especially adaptive under the time and resource limitations that prevail in many emergency departments (EDs), but occasionally they fail. When they do, we refer to them as cognitive errors. They are costly but highly preventable. It is important that emergency physicians be aware of the nature and extent of these heuristics and biases, or cognitive dispositions to respond (CDRs). Thirty are catalogued in this article, together with descriptions of their properties as well as the impact they have on clinical decision making in the ED. Strategies are delineated in each case, to minimize their occurrence. Detection and recognition of these cognitive phenomena are a first step in achieving cognitive de-biasing to improve clinical decision making in the ED.

https://onlinelibrary.wiley.com/doi/pdf/10.1197/aemj.9.11.1184

Achieving quality in clinical decision making: cognitive strategies and detection of bias.

Cognitive forcing strategies in clinical decisionmaking

The purpose of the trauma team is to provide advanced simultaneous care from relevant specialists to the seriously injured trauma patient. When functioning well, the outcome of the trauma team performance should be greater than the sum of its parts. Trauma teams have been shown to reduce the time taken for resuscitation, as well as time to CT scan, to emergency department discharge and to the operating room. These benefits are demonstrated by improved survival rates, particularly for the most severely injured patients, both within and outside of dedicated trauma centres. In order to ensure the best possible performance of the team, the leadership skills of the trauma team leader are essential and their non-technical skills have been shown to be particularly important. Team performance can be enhanced through a process of audit and assessment of the workings of the team and the evidence currently available suggests that this is best facilitated through the process of video review of the trauma resuscitation. The use of human patient simulators to train and assess trauma teams is becoming more commonplace and this technique offers a safe environment for the future education of trauma team staff. Trauma teams are a key component of most programmes which set out to improve trauma care. This article reviews the background of trauma teams, the evidence for benefit and potential techniques of performance assessment. The review was written after a PubMed, Ovid, Athens, Cochrane and guideline literature review of English language articles on trauma teams and their performance and hand searching of references from the relevant searched articles.

/pdf/the-performance-and-assessment-of-hospital-trauma-teams-5167ftczyq.pdf

The performance and assessment of hospital trauma teams.

Hypothesis This project tested the hypothesis that computer-aided decision support during the first 30 minutes of trauma resuscitation reduces management errors. Design Ours was a prospective, open, randomized, controlled interventional study that evaluated the effect of real-time, computer-prompted, evidence-based decision and action algorithms on error occurrence during initial resuscitation between January 24, 2006, and February 25, 2008. Setting A level I adult trauma center. Patients Severely injured adults. Main Outcome Measures The primary outcome variable was the error rate per patient treated as demonstrated by deviation from trauma care algorithms. Computer-assisted video audit was used to assess adherence to the algorithms. Results A total of 1171 patients were recruited into 3 groups: 300 into a baseline control group, 436 into a concurrent control group, and 435 into the study group. There was a reduction in error rate per patient from the baseline control group to the study group (2.53 to 2.13, P  = .004) and from the control group to the study group (2.30 to 2.13, P  = .04). The difference in error rate per patient from the baseline control group to the concurrent control group was not statistically different (2.53 to 2.30, P  = .21). A critical decision was required every 72 seconds, and error-free resuscitations were increased from 16.0% to 21.8% ( P  = .049) during the first 30 minutes of resuscitation. Morbidity from shock management ( P  = .03), blood use ( P P  = .046) were decreased. Conclusions Computer-aided, real-time decision support resulted in improved protocol compliance and reduced errors and morbidity. Trial Registration clinicaltrials.gov Identifier:NCT00164034

https://jamanetwork.com/journals/jamasurgery/articlepdf/406736/soa05033_218_225.pdf

Trauma Resuscitation Errors and Computer-Assisted Decision Support

ACADEMIC EMERGENCY MEDICINE 2012; 19:37–47 © 2012 by the Society for Academic Emergency Medicine

Abstract
Objectives:  Systematic evaluation of prehospital provider performance during actual resuscitations is difficult. Although prior studies reported pediatric drug-dosing mistakes and other types of management errors, the underlying causes of those errors were not investigated. The objective of this study was to identify causes of errors during a simulated, prehospital pediatric emergency.

Methods:  Two-person emergency medical services (EMS) crews from five geographically diverse agencies participated in a validated simulation of an infant with altered mental status, seizures, and respiratory arrest using their own equipment and drugs. A scoring protocol was used to identify errors. A debriefing conducted by a trained facilitator immediately after the simulated event elicited root causes of active and latent errors, which were analyzed by thematic qualitative assessment methods.

Results:  Forty-five crews completed the study. Clinically important themes that emerged from the data included oxygen delivery, equipment organization and use, glucose measurement, drug administration, and inappropriate cardiopulmonary resuscitation. Delay in delivery of supplemental oxygen resulted from two different automaticity errors and a 54% failure rate in using an oropharyngeal airway (OPA). Most crews struggled to locate essential pediatric equipment. Three found broken or inoperable bag/valve/masks (BVMs), resulting in delayed ventilation. Some mistrusted their intraosseous (IO) injection gun device; others used it incorrectly. Only 51% of crews measured blood glucose; some discovered that glucometers were not stored in their sealed pediatric bags. The error rate for diazepam dosing was 47%; for midazolam, it was 60%. Underlying causes of dosing errors were found in four domains (cognitive, procedural, affective, and teamwork), and they included incorrect estimates of weight, incorrect use of the Broselow pediatric emergency tape, faulty recollection of doses, difficulty with calculations under stress, mg/kg to mg to mL conversion errors, inaccurate measurement of volumes, use of the wrong end of prefilled syringes, and failure to crosscheck doses with partners.

Conclusions:  Simulation, followed immediately by facilitated debriefing, uncovered underlying causes of active cognitive, procedural, affective, and teamwork errors, latent errors, and error-producing conditions in EMS pediatric care.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2011.01252.x

Root causes of errors in a simulated prehospital pediatric emergency.

Objective A computer-based system to apply trauma resuscitation protocols to patients with penetrating thoracoabdominal trauma was previously validated for 97 consecutive patients at a Level 1 trauma center by a panel of the trauma attendings and further refined by a panel of national trauma experts. The purpose of this article is to describe how this system is now used to objectively critique the actual care given to those patients for process errors in reasoning, independent of outcome. Methods A chronological narrative of the care of each patient was presented to the computer program. The actual care was compared with the validated computer protocols at each decision point and differences were classified by a predetermined scoring system from 0 to 100, based on the potential impact on outcome, as critical/noncritical/no errors of commission, omission, or procedure selection. Results Errors in reasoning occurred in 100% of the 97 cases studied, averaging 11.9/case. Errors of omission were more prevalent than errors of commission (2. 4 errors/case vs 1.2) and were of greater severity (19.4/error vs 5. 1). The largest number of errors involved the failure to record, and perhaps observe, beside information relevant to the reasoning process, an average of 7.4 missing items/patient. Only 2 of the 10 adverse outcomes were judged to be potentially related to errors of reasoning. Conclusions Process errors in reasoning were ubiquitous, occurring in every case, although they were infrequently judged to be potentially related to an adverse outcome. Errors of omission were assessed to be more severe. The most common error was failure to consider, or document, available relevant information in the selection of appropriate care.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2000.tb00480.x

H R Champion

Papers

An objective analysis of process errors in trauma resuscitations.