Improvement Insights

By Elizabeth Lazzara, PhD; Joseph Keebler, PhD; and Jordan Rogers, PhD

Evidence has repeatedly demonstrated that adverse events are of significant concern in modern day healthcare systems.¹ These events can lead to mortality as well as produce significant costs such as lost income, decreased productivity, additional healthcare expenses, and disability, resulting in an approximated cost of nearly one trillion dollars annually.² 

Regulatory agencies, administrators, researchers, and clinicians recognize the prevalence and severity of adverse events. Because these events continue to persist, a need remains for various investigatory methods. There are four methods that hospitals typically employ to investigate and analyze adverse events that have occurred: 

• Root cause analysis (RCA): Identifies the primary causal factors of an event to prevent similar events from occurring.
• Legal and risk department assessment: Evaluates specific cases in which medical errors may have occurred.
• Morbidity and mortality (M&M) conferences: Discusses cases in which medical errors and/or complications resulted in patient morbidity or mortality.
• Medical grand rounds (MGR): Presents case studies alongside related research. 

Our open access commentary in a recent issue of The Joint Commission Journal on Quality and Patient Safety, “How to Mitigate the Effects of Cognitive Biases During Patient Safety Incident Investigations,” explores how biases often exist during adverse event investigations in healthcare, including: 

• Hindsight bias: Perceives an outcome as more predictable than it actually was.
• Availability heuristic: Bases decisions on easily accessible information. 
• Fundamental attribution error: Attributes an outcome on an individual’s traits rather than their circumstances.
• Confirmation bias: Selects information that supports one’s beliefs and ignores information that does not. 
• Groupthink: Prioritizes concurrence and suppresses individual perspectives. 

Recognizing that humans are involved in investigatory methods, it is important to understand and ameliorate relevant biases. With these specific biases in mind, our commentary proposed several strategies to help mitigate the existence and implications of biases, including: 

• Employing a bottom-up approach by avoiding focus on the outcome.
• Having analysts consider decisional alternatives within appropriate context.
• Developing a thorough case description that includes information beyond just that which is most recent and salient.
• Using a multidisciplinary investigation team to avoid a faulty focus.
• Employing systems thinking to shift the focus from the individual to the context of their tasks, technologies, and environment.
• Utilizing a large, multidisciplinary team of stakeholders with varying perspectives. 
• Encouraging stakeholders to speak up and share their perspectives.
• Dividing up a group to eliminate unfounded consensus.
• Conducting 1:1 interviews to limit the influence of others.
• Requesting authoritarian figures to periodically leave so their viewpoints are not imposed.

We hope your organization finds the mitigation strategies helpful when trying to minimize cognitive biases and reduce the influence it has on providers and patients, and most importantly on patient safety and quality of care. 

References 

1. Eldridge N, Wang Y, Metersky M, et al. Trends in adverse event rates in hospitalized patients, 2010-2019. JAMA. 2022;328(2):173-183. 
2. Andel C, Davidow SL, Hollander M, et al. The economics of health care quality and medical errors. J Health Care Finance 2012;39(1):39-50. 

Elizabeth Lazzara, PhD, is an Associate Professor in the Department of Human Factors and Behavioral Neurobiology at Embry-Riddle Aeronautical University in Daytona Beach, Florida. Dr. Lazzara’s research focuses on improving quality of patient care within the healthcare domain as related to human performance, teamwork, team training, simulation-based training, and performance measurement.  

Joseph Keebler, PhD, is an Associate Professor in the Department of Human Factors and Behavioral Neurobiology at Embry-Riddle Aeronautical University. Dr. Keebler conducts experimental and applied research in human factors, with a specific focus on training and teamwork in medical, military, and consumer domains. 

Jordan Rogers, PhD, is a Human Factors Engineer at Intuitive in Raleigh, North Carolina. Dr. Rogers has expertise in human factors engineering with an interest in understanding the role of human factors within medical device development and healthcare systems. Her work focuses on a variety of areas, including consulting, hospitals, and medical devices.