NAEMSP: How Errors Happen

Why do people make errors? And, more important to EMS, how can we reduce ours?

Definitive answers to those questions could make someone richer than any of us, but we do know a few things about how mistakes happen and what might reduce them. Emergency doc Will Smith, MD, FAEMS, provided an outline Thursday on the opening day of the National Association of EMS Physicians’ annual meeting in San Diego.

The sophisticated answer is heuristics—unconscious mental shortcuts people develop as aids in problem-solving or discovery processes. They’re more practical than rational but can help us reach short-term goals.

How do you know some patients are sick? Your heuristics might include educated guesses, common sense, rules of thumb, familiarity, or contagion. Sometimes they’ll be right—and sometimes not.

There are three basic types of medical errors, Smith said:

• Procedural—technical mistakes that should become less frequent with time and experience (e.g., as with intubation or IV placement);
• Affective—errors resulting from emotions, positive or negative, toward an individual or situation; and
• Cognitive—mistaken thought processes or decisions reached.

If practice can reduce procedural errors and keeping emotions in check can diminish the affective, cognitive errors can be a bit tougher. Canadian emergency physician Pat Croskerry, MD, PhD, defined more than 30 types in a 2003 article published in Academic Medicine. EMS providers could be susceptible to any of them, but Smith cited five of particular note:

• Anchoring—locking on to key features in a patient’s presentation too early in the diagnostic process and not revising that impression with later information.
• Availability—judging things as more frequent or likely if they come easily to mind. Smith cited Ebola and anthrax as big-news examples that could weigh on providers’ minds; Croskerry notes diseases seen recently may be more likely to be diagnosed and those unseen in some time may be less likely.
• Commission bias—a tendency toward action leading to overtreatment or trying to do too much. Think of the superenthused newbie who wants to use every tool and drug in the rig on every shift.
• Omission bias—the opposite is missing things, rooted, Croskerry notes, in the aim of trying to do no harm.
• Search satisfying—if you have an apparent answer, you stop searching. This can lead to important problems being missed: comorbidities, other fractures, coingestants, etc.

Metacognition, or considering our own thought processes, can help us identify and reduce these errors, Smith said. He also offered some specific tools that can help:

• Incorporate simulation into training;
• Force consideration of alternative diagnoses;
• Beware of diagnostic labels, especially at handoffs and transitions of care;
• Seek feedback and modify your care as appropriate; and
• Use checklists and reference materials liberally.

John Erich is the senior editor of EMS World.