Editing Medical error (section)

=== Human factors and ergonomics ===
[[File:Okunuşu,yazılışı yakın ilaçlar.jpg|thumb|250px|A plate written in a hospital, containing drugs that are similar in spelling or writing]]
[[Human error|Cognitive errors]] commonly encountered in medicine were initially identified by psychologists [[Amos Tversky]] and [[Daniel Kahneman]] in the early 1970s. [[Jerome Groopman]], author of ''[[How Doctors Think]]'', says these are "cognitive pitfalls", biases which cloud our logic. For example, a practitioner may overvalue the first data encountered, skewing their thinking. Another example may be where the practitioner recalls a recent or dramatic case that quickly comes to mind, coloring the practitioner's judgement. Another pitfall is where [[stereotypes]] may prejudice thinking.<ref>{{cite magazine |url=http://www.nybooks.com/articles/archives/2009/nov/05/diagnosis-what-doctors-are-missing/ |title=Diagnosis: What Doctors are Missing |author=Jerome E. Groopman |date=5 November 2009 |magazine=[[New York Review of Books]] |author-link=Jerome E. Groopman |access-date=July 9, 2014 |archive-date=September 17, 2015 |archive-url=https://web.archive.org/web/20150917174143/http://www.nybooks.com/articles/archives/2009/nov/05/diagnosis-what-doctors-are-missing/ |url-status=live }}</ref>  Pat Croskerry describes clinical reasoning as an interplay between intuitive, subconscious thought (System 1) and deliberate, conscious rational consideration (System 2).  In this framework, many cognitive errors reflect over-reliance on System 1 processing, although cognitive errors may also sometimes involve System 2.<ref>{{cite journal |last1=Croskerry |first1=P. |year=2009 |title=A Universal Model of Clinical Reasoning |journal=Acad Med |volume=84 |issue=8 |pages=1022–8 |doi=10.1097/ACM.0b013e3181ace703 |pmid=19638766 |doi-access=free}}</ref>

[[Sleep deprivation]] has also been cited as a contributing factor in medical errors.<ref name=":0">{{cite journal |last1=Ker |first1=Katharine |last2=Edwards |first2=Philip James |last3=Felix |first3=Lambert M |last4=Blackhall |first4=Karen |last5=Roberts |first5=Ian |date=12 May 2010 |title=Caffeine for the prevention of injuries and errors in shift workers |journal=Cochrane Database of Systematic Reviews |volume=2010 |issue=5 |pages=CD008508 |doi=10.1002/14651858.CD008508 |pmc=4160007 |pmid=20464765}}</ref> One study found that being awake for over 24 hours caused [[medical interns]] to double or triple the number of preventable medical errors, including those that resulted in injury or death.<ref>{{cite journal |last1=Barger |first1=L. K. |last2=Ayas |first2=N. T. |last3=Cade |first3=B. E. |last4=Cronin |first4=J. W. |last5=Rosner |first5=B. |last6=Speizer |first6=F. E. |last7=Czeisler |first7=C. A. |display-authors=1 |year=2006 |title=Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures |journal=PLOS Med |volume=3 |issue=12 |page=e487 |doi=10.1371/journal.pmed.0030487 |pmc=1705824 |pmid=17194188 |doi-access=free }}</ref> The risk of car crash after these shifts increased by 168%, and the risk of [[Near miss (safety)|near miss]] by 460%.<ref name="npr">{{Cite web |url=https://www.npr.org/templates/story/story.php?storyId=6619687 |title=When Doctors Don't Sleep |website=[[NPR]] |access-date=April 3, 2018 |archive-date=May 9, 2021 |archive-url=https://web.archive.org/web/20210509151219/https://www.npr.org/templates/story/story.php?storyId=6619687 |url-status=live }}</ref> Interns admitted falling asleep during lectures, during rounds, and even during surgeries.<ref name="npr" /> Night shifts are associated with worse surgeon performance during laparoscopic surgeries.<ref name=":0" />

Practitioner risk factors include fatigue,<ref>{{cite journal |last1=Nocera |first1=Antony |last2=Khursandi |first2=Diana Strange |title=Doctors' working hours: can the medical profession afford to let the courts decide what is reasonable? |journal=Medical Journal of Australia |date=June 1998 |volume=168 |issue=12 |pages=616–618 |doi=10.5694/j.1326-5377.1998.tb141450.x |pmid=9673625 |s2cid=34759813 }}</ref><ref name="pmid15509817">{{cite journal |last1=Landrigan |first1=Christopher P. |last2=Rothschild |first2=Jeffrey M. |last3=Cronin |first3=John W. |last4=Kaushal |first4=Rainu |last5=Burdick |first5=Elisabeth |last6=Katz |first6=Joel T. |last7=Lilly |first7=Craig M. |last8=Stone |first8=Peter H. |last9=Lockley |first9=Steven W. |last10=Bates |first10=David W. |last11=Czeisler |first11=Charles A. |title=Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive Care Units |journal=New England Journal of Medicine |date=28 October 2004 |volume=351 |issue=18 |pages=1838–1848 |doi=10.1056/NEJMoa041406 |pmid=15509817 |doi-access=free }}</ref><ref>{{cite journal |last1=Barger |first1=Laura K |last2=Ayas |first2=Najib T |last3=Cade |first3=Brian E |last4=Cronin |first4=John W |last5=Rosner |first5=Bernard |last6=Speizer |first6=Frank E |last7=Czeisler |first7=Charles A |last8=Mignot |first8=Emmanuel |title=Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures |journal=PLOS Medicine |date=12 December 2006 |volume=3 |issue=12 |pages=e487 |doi=10.1371/journal.pmed.0030487 |pmid=17194188 |pmc=1705824 |doi-access=free }}</ref>
depression,<ref name="Association Between Physician Depre">{{cite journal |last1=Pereira-Lima |first1=K |last2=Mata |first2=DA |last3=Loureiro |first3=SR |last4=Crippa |first4=JA |last5=Bolsoni |first5=LM |last6=Sen |first6=S |year=2019 |title=Association Between Physician Depressive Symptoms and Medical Errors: A Systematic Review and Meta-analysis |journal=JAMA Network Open |volume=2 |issue=11 |pages=e1916097 |doi=10.1001/jamanetworkopen.2019.16097 |pmid=31774520 |pmc=6902829 }}</ref> and burnout.<ref>{{cite journal |last1=Fahrenkopf |first1=Amy M |last2=Sectish |first2=Theodore C |last3=Barger |first3=Laura K |last4=Sharek |first4=Paul J |last5=Lewin |first5=Daniel |last6=Chiang |first6=Vincent W |last7=Edwards |first7=Sarah |last8=Wiedermann |first8=Bernhard L |last9=Landrigan |first9=Christopher P |title=Rates of medication errors among depressed and burnt out residents: prospective cohort study |journal=BMJ |date=1 March 2008 |volume=336 |issue=7642 |pages=488–491 |doi=10.1136/bmj.39469.763218.BE |pmid=18258931 |pmc=2258399 }}</ref>
Factors related to the clinical setting include diverse patients, unfamiliar settings, time pressures, and increased patient-to-nurse staffing ratio increases.<ref>{{cite journal |last1=Aiken |first1=Linda H. |last2=Clarke |first2=SP |last3=Sloane |first3=DM |last4=Sochalski |first4=J |last5=Silber |first5=JH |title=Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction |journal=JAMA |date=23 October 2002 |volume=288 |issue=16 |pages=1987–93 |doi=10.1001/jama.288.16.1987 |pmid=12387650 |doi-access=free }}</ref>
Drug names that look alike or sound alike are also a problem.<ref>{{cite web | last=8th Annual MEDMARX Report | date=2008-01-29 | url=http://www.usp.org/aboutUSP/media/newsCenter.html?article=105435 | title=Press Release | publisher=U.S. Pharmacopeia | access-date=2008-03-23 | url-status=dead | archive-url=https://archive.today/20080208093723/http://www.usp.org/aboutUSP/media/newsCenter.html?article=105435 | archive-date=2008-02-08 }}</ref>

Errors in interpreting medical images are often perceptual instead of "fact-based"; these errors are often caused by failures of attention or vision.<ref name="Analysis of Perceptual Expertise in">{{cite journal |last1=Waite |first1=Stephen |last2=Grigorian |first2=Arkadij |last3=Alexander |first3=Robert G. |last4=Macknik |first4=Stephen L. |last5=Carrasco |first5=Marisa |last6=Heeger |first6=David J. |last7=Martinez-Conde |first7=Susana |title=Analysis of Perceptual Expertise in Radiology – Current Knowledge and a New Perspective |journal=Frontiers in Human Neuroscience |date=25 June 2019 |volume=13 |pages=213 |doi=10.3389/fnhum.2019.00213 |pmid=31293407 |pmc=6603246 |doi-access=free }}</ref> For example, visual illusions can cause radiologists to misperceive images.<ref>{{cite journal |last1=Alexander |first1=Robert |last2=Yazdanie |first2=Fahd |last3=Waite |first3=Stephen Anthony |last4=Chaudhry |first4=Zeshan |last5=Kolla |first5=Srinivas |last6=Macknik |first6=Stephen |last7=Martinez-Conde |first7=Susana |title=Visual Illusions in Radiology: untrue perceptions in medical images and their implications for diagnostic accuracy |journal=Frontiers in Neuroscience |year=2021 |volume=15 |page=629469 |doi=10.3389/fnins.2021.629469|pmid=34177444 |pmc=8226024 |doi-access=free }}</ref>

A number of Information Technology (IT) systems have been developed to detect and prevent medication errors, the most common type of medical errors.<ref>{{Cite book|last=Anderson|first=J.G.|title=Information technology for detecting medication errors and adverse drug events. (Expert Opin Drug Saf 3)|year=2005|pages=449–455}}</ref> These systems screen data such as ICD-9 codes, pharmacy and laboratory data. Rules are used to look for changes in medication orders, and abnormal laboratory results that may be indicative of medication errors and/or adverse drug events.<ref>{{Cite journal|last1=Abrahamson|first1=Kathleen|last2=Anderson|first2=J.G.|year=2017|title=Your Health Care May Kill You: Medical Errors|journal=Studies in Health Technology and Informatics|volume=234|issue=Building Capacity for Health Informatics in the Future|pages=13–17|doi=10.3233/978-1-61499-742-9-13|pmid=28186008|url=https://ebooks.iospress.nl/publication/46132|access-date=September 2, 2021|archive-date=September 2, 2021|archive-url=https://web.archive.org/web/20210902215631/https://ebooks.iospress.nl/publication/46132|url-status=live|url-access=subscription}}</ref>