Cognition has been recognized as a human factor that can contribute to failures in health care. This review examines cognitive aspects of human error that affect patient safety, methods to augment detection of flawed decision-making, and the potential for educational approaches like virtual reality simulation to train physicians to manage cognitive error once it occurs. A Perspective interview with Dr. Pat Croskerry explored the role of cognition in medical error.

The patient safety risks associated with handoffs have been well documented. As a result, multiple investigators have developed standardized tools to improve the quality of information transfer during handoffs. What remains unclear is the extent to which standardizing the handoff process improves patient safety. This systematic review of 36 studies examining the effectiveness of handoff tools found that most tools were not evaluated rigorously and did not specifically assess the effect of standardizing handoffs on patient-level outcomes. Therefore, the authors were unable to reach conclusions regarding the optimal methods for improving the quality of handoffs. Similar problems were noted in studies of checklists, another widely implemented safety intervention, highlighting both the difficulty and the importance of strictly evaluating patient safety interventions.

Direct observation of handoffs in the intensive care unit was used to develop a new framework for improving handoffs that emphasizes the importance of ensuring overall continuity of care.

This study found that expert nurses with more than 10 years of dialysis experience were more effective at detecting and correcting errors compared with non-experts, particularly for procedurally based errors.

This study explored information signals and their interpretation by pharmacists to better understand their reasoning in generating hypotheses about adverse drug events.

This review article describes approaches to safety improvement that specifically address the complex nature of the clinical health care environment.

This qualitative study reported the user, pump design problems, and lack of training as the most frequent factors attributed to adverse events with medical devices.

This study describes several instances of near misses that occurred due to patient misidentification, such as physicians being unable to access previous test results because—unknown to them—the patient had been assigned a second medical record number. The investigators used human factors analysis to identify the underlying systems issues that contributed to these errors. Previous studies in adult and pediatric inpatients have also identified patient misidentification as a potential contributor to a large number of errors.

The investigators shadowed emergency department nurses and physicians and identified the types of interruptions that occurred and what factors contributed to them.

In this prospective study of psychiatric emergency care, the researchers analyzed audiotaped interactions that included miscommunication incidents or perceived violations of accepted practice to identify potential errors.

This study evaluated factors that jeopardize safe decision-making using ethnographic observation and interviews. Using a high-paced emergency department (ED) setting, investigators discovered that interruptions occurred nearly every 10 minutes for attending physicians. Observed gaps in communication resulted from poor information flow complicated by inherent multitasking, shift changes, and other activities such as documentation time and utilization of computer resources. The authors present typical workflow patterns in the ED and provide a summary of interview responses to illustrate the taxing nature of cognitive overload facing the studied clinicians. They conclude that carefully designed technology can minimize the effect that interruptions and handoffs have on patient safety.

This case study analyzes a potassium chloride (KCl) dosing error in a system using computerized provider order entry (CPOE). The authors identified problems related to screen results, usability, training, and others. They use their findings to suggest improvements in their hospital’s CPOE system and to analyze CPOE system–related errors more generally.

The authors present issues related to cognition in nursing practice and how these might be applied to design effective clinical information systems.

Using the concepts of "sharp" and "blunt" ends of practice, this article explores health professionals' differing opinions on biomedical device-related errors. Investigators requested that study participants express their views on events surrounding three true-error scenarios. Analysis of the transcribed responses revealed that interpretation varied widely between groups. While clinicians focused on clinical and human factors, biomedical engineers focused on device-related issues, and administrators emphasized documentation and training. The authors conclude that individual expertise largely mediates an error analysis, as no single interpretation provides a comprehensive view of all contributing factors.