“The human brain is a complex organ with the wonderful power of enabling man to find reasons for continuing to believe whatever it is that he wants to believe. – Voltaire” (O’Sullivan & Schofield, 2018) Cognitive Biases Defined Cognitive biases, defined as “flaws or distortions in judgment and decision-making” (Joint Commission, 2016, p.1), have been …
Cognitive Biases as Contributing Factors to Medical Errors Read More »
A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm dates. Early the next morning, intravenous oxytocin was administered to induce labor. When the obstetrics team rounded on the patient several hours later, AROM (artificial rupture of membranes) was recommended to accelerate labor. The intern reviewed the patient’s chart …
How does learning occur from adverse events, near misses, and errors? One method is through root cause analysis (RCA). RCA is a systematic process in which adverse events and near misses are investigated. This approach came from high-risk industries such as nuclear power and aviation and was modified for health care as the patient safety …