“If you guys can’t think to order pregnancy tests, we’ve got big problems!” the consultant said.

He was a heart expert, but he remembered medical school:  women of childbearing age with abdominal pain and/or bleeding must have pregnancy tests.

We forget simple things, make simple cognitive errors, all the time.

Intelligence or experience will not protect you.

Every day brilliant people forget to:

• close their zippers,
• signal lane changes,
• turn off the oven,
• feed the cat,
• lock the door

Medicine overflows with cognitive traps. It brims with safety-critical activity: you get only one chance to do something right or patients will suffer & die.

For example, a missed ectopic pregnancy can cause a woman to bleed to death.   An ectopic exists in 6-16% of women with pain and bleeding in the ED.  Every medical student learns early that ordering a pregnancy test can save lives.

But very rarely, blood-work gets ordered without a pregnancy test when providers are left to order lab tests separately.

The consultant believed emergency docs must be even more stupid than he suspected.  How could they miss something every medical student knows?

Uninformed individuals still blame people; experts tell us to blame the system.

Errors do not happen for lack of knowledge. 

We must improve the system and stop the ‘blame and shame’.

System solutions – 2 examples:

Behaviour-shaping constraints, or forcing functions.  For example, you cannot get your bank slip from a bank machine without collecting your bank card first; you cannot start your microwave without closing the door first; you can’t start your car without putting it into park. Constraints prevent medical mistakes.

Opt out vs. opt in: these terms get used in advertising and mailing lists.  To capture everyone for a list, advertisers put people on the list until they ask to be taken off.  Advertisers assume you want to be on the list, opt in is assumed, until you opt out.  (Opt out pops up in discussions about ways to increase organ donation)

Using opt out for lab panels for women of childbearing age with abdominal pain could decrease the chance of forgetting a pregnancy test.  Providers could opt out of performing the pregnancy test, but would be forced to think about it first.

Some still resist system solutions and try to blame people for medical errors.  What do you think?  Can we rely on system design to decrease error?