Medical professionals need to move away from placing blame on individuals to thinking from a systems perspective. Systems changes aimed at preventing future error patterns, making visible those errors that cannot be prevented, and buffering or protecting patients from the consequences of errors that slip through are at the heart of patient safety efforts. Emergency physician training has devoted minimal attention to cognitive behaviors despite an established literature on medical decision-making. Most of us do not desire to be cognitive psychologists, but understanding the basics of reasoning strategies, cognitive biases, and forcing strategies may help prevent many medical errors. This process is not a conscious one subjects are not willfully ignoring conflicting information, but simply failing to perceive it.
Good teamwork is a powerful general tool for preventing errors and reducing their impact.
Three specific teamwork behaviors may have prevented the error in this case. A second behavior shown by highly trained teams is cross-monitoring of each other s actions. Cross-monitoring is not naturally part of physicians culture, but could have caught the mental lapse that led to this error. The third team behavior involves advocacy and situational leadership, such as speaking out when mental models diverge, questioning a course of action, or suggesting a course of action different than that being planned. Social pressures make it difficult for lower ranking members of teams to engage in this behavior, even when members are on the best of terms, so explicit efforts are needed to elicit advocacy and assertion.