Something that struck me during the first day was how it seems that our thinking as humans predisposes us towards medical errors. We are fallible beings with a limited capacity for understanding complexity practicing in a field with infinite complexities. We have to use heuristics, or mental shortcuts, because if we didn’t we would be inundated with so much information that we would become incapacitated. When this thinking goes wrong, we fall victim to confirmation bias and our patients can suffer. While this can be combatted through more mindful practice, overcoming thinking patterns that have persisted through millennia of evolution is no small feat. I ended the first day feeling discouraged that better safety outcomes would only come through a constant battle against our inherent thinking patterns.

 

During the second day, a different heuristic came to mind. The availability heuristic is the idea that we judge the probability of… Continue reading →

My first experience with patient safety came during my junior year of college when I was interning in a gastroenterology practice. I had spent three years learning about the problems facing the healthcare system from professors who were passionate about fixing it. I had read, for example, about the role of checklists in reforming the aviation industry and their promising application in healthcare. I was excited when on my first day, I watched as one physician started each and every procedure with a timeout, diligently going through each step of the checklist before beginning. Afterword, he eagerly told me about the strong evidence supporting checklists’ use and how he felt that they had improved his own practice since he started using them. Over the next few days, I was surprised to see that some physicians only occasionally completed the time outs while some signed the form without doing anything at… Continue reading →