It’s 5pm and as the paediatric registrar, you are handing over your patients to the evening team. As you are talking, you look at the team. Their eyes are glazed and they are staring into the middle distance. Was it something you said?
Perhaps we’re all not as smart as we think we are. Perhaps the reason why we are making the same mistakes over and over is not due to a lack of knowledge but due to problems in the how we think and how we make decisions.
A “cognitive bias” in the setting of medicine refers to the error in judgement in a clinician’s decision making process. In these politically correct times, this definition has been deemed to be too “emotionally loaded” leading to a new term called “Cognitive Disposition to Respond” or CDR. This new term takes away the negative connotations associated with “cognitive bias” and its negative association with errors, fallacies, heuristics etc. After all, doctors don’t like to admit that we make mistakes!
There are over 30 different types of cognitive decisions to respond, but we will be talking about just one.
One particular type of CDR is called “Order Effects”. This is the phenomenon whereby we tend to remember what is said at the beginning of a story and also what is said at the end, but we often forget the details in the middle. As you can imagine this can be a problem at times of information transfer, specifically at handover.
Consider this: over 7 million handovers are performed in Australian hospitals each year and over 26 million handovers in the community setting. That leaves us with a lot of opportunities for miscommunication and subsequently for lots of mistakes to be made. In fact, the “breakdown in the transfer of information has been identified as one of the most important contributing factors in serious adverse events and is a major preventable cause of patient harm”.
And if you don’t want to get sued then consider that a review of malpractice cases in the USA showed that 70% of them were caused by teamwork problems with the biggest issues within teamwork being supervision and handover.
If you still don’t think that a quality handover is important, then think about the poor night residents on the paediatric ward. One study of paediatric ward residents revealed that the only variable found to “affect the perception of preparedness for the night shift was the quality of handover received”. It didn’t matter how many patients they had, how sick the patients were, how short-staffed they were…all they wanted was an adequate handover.
Thankfully the experts agree that the best thing that you can do to overcome a cognitive bias is to be aware that it exists. And now you do. But better than that, you can now use it to your advantage.
If you’re receiving handover, then make sure that you pay close attention to what is said in the middle of the handover, not just at the start and the end.
If you’re delivering handover, then be aware that those receiving your handover probably aren’t paying attention by the halfway mark but if you know that you’re saying something important then it may be worth repeating it at the end.
Australian Commission on Safety and Quality in Health Care, National Safety and Quality Health Service Standards (September 2012). Sydney. ACSQHC, 2012.
Cosby KS Croskerry P Patient Safety: A Curriculum for Teaching Patient Safety in Emergency Medicine Acad Emerg Med Jan 2003 vol 10 (1)
Croskerry P. Diagnostic Failure: A Cognitive and Affective Approach. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb
Crockery P The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003 Aug;78(8):775-80.
Horowitz SM Waggoner-Fountain LA Bass EJ Sledd RM Adequacy of information transferred at resident sign-out (inhospital handover of care): a prospective survey Qual Saf Health Care 2008;17:6-10
Wong MC, Yee KC, Turner P. (2008) Clinical Handover Literature Review. eHealth Services Research Group, University of Tasmania, Australia.