Studies by Croskerry and Norman on critical thinking and decision-making in EDs in the United States, Canada, and Australia have identified 25 processes that contribute to medical errors. Apart from the system errors mentioned previously, almost one half of these resulted from individual error (ie, faulty decision-making, mistriage, and cognitive and emotional biases). Croskerry and Norman identified that the manner in which clinicians working the ED environment inherently think, although a necessary approach to care in the ED, may also be a key source of error.
Emergency providers combine two thought processes. The first can be simplified as "pattern recognition," and it is characterized by mental shortcuts and reflexive reactions to patients' clinical presentations. This is, in fact, what many would call gestalt: An experienced clinician will recognize certain aspects of a disease presentation, rapidly come to diagnostic closure, and then proceed with his or her plan of action. The second thought process is deductive, rational, rule-based, and low in emotional investment.
Both of these processes are essential to the practice of emergency healthcare, and studies have shown that pure reliance on either of the two processes results in more errors.[10,11] Clinicians in the ED must strive to balance both thought processes and use each in the appropriate context in order to deal with critically ill patients. In this case, radiography of the shoulder was ordered, which suggests that injury was suspected; however, there was a failure to follow the rule that extraneous material not be present.
To prevent this type of error from recurring, a systems approach would entail an inquiry into why this failure occurred. Was it because the clinicians were unaware of or disagreed with the rule? This would indicate a training issue. Were they too busy? This would point to a workforce scheduling issue. Perhaps the radiology team had become lax about removing hardware because they had not done so in many cases, without harm. That would be an example of "normalized deviance," wherein an unsafe practice becomes accepted as part of everyday routine by the whole team; this is most likely to occur in situations where the consequences of deviation from an accepted practice are ambiguous or seem to be of very low frequency.
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