Authors: Mary Salisbury, RN, MSN, andSusan M. Hohenhaus, MA, RN, FAEN, Wellsboro, Pa

Cognitive Errors

Teamwork and Cognitive Error

Know the Plan, Share the Plan, Review the Risks in Action

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C L I N I C A L N U R S E S F O R U MKnow the Plan, Sh

the Risks: A Method of S

for the EmergeMary Salisbury is President, The Cedar Institute, Inc., N. Kingstown, RI.

Susan M. Hohenhaus is President, Hohenhaus & Associates, Inc,Wellsboro, Pa.

For correspondence, write: Susan M. Hohenhaus, MA, RN, FAEN,6 Willard Terrace, Wellsboro, PA 16901; E-mail: shohenha@ptd.net.

J Emerg Nurs 2008;34:46-8.

0099-1767/$34.00

Copyright n 2008 by the Emergency Nurses Association.doi: 10.1016/j.jen.2007.11.008

46cannot state the names or ages of her children, and is

intolerant of light. Her blood pressure is 140/90 mm/Hg;

her temperature is 98.28F; her pulse is 88 beats perMrs J, suffering from a headache of intolerable

proportions, arrives at a level I trauma center

with the worst headache of my life. The

triage nurse is worried about a subarachnoid hemorrhage

(SAH) and immediately assigns a bed. Mrs J is evaluated

by a veteran ED physician-nurse-technician team, who noted

the following information:

Situation. The patient is a 53-year-old female

secretary, the mother of 5, who was driven from work

by a friend. She presents with a 4-hour history, sudden

onset, crushing, worst headache of my life.

Background. The patient denies trauma or another

precipitating event. Her head and neck pain is reported as

10 on a scale of 10, unrelieved by acetaminophen 6 inthe past 16 hours.

Assessment. The patient is curled in a side-lying

position on a stretcher, her coat over her head, her eyes

closed. She arouses with difficulty in response to her name,

is slow to answer, is confused regarding time and place,

e the Plan, Review

uctured Communication

y Care Settingminute; her respirations are 22 breaths per minute and

shallow; arterial oxyhemoglobin saturation is 92% on

room air.

Recommendation. Perform a work up to rule

out SAH.

Mrs J is sent for a computed tomography scan without

contrast. Despite the working diagnosis and the lack of a

fever, the ED attending physician has a gut instinct that

Mrs J has meningitis and orders a retake temperature.

No additional discussion occurs between the nurse and

the attending physician, who is called to another case. A

JOURNAL OF EMERGENCY NURSING 34:1 February 2008

sions and is an example of how humans use simplifying

develop contingency plans to mitigate or negate f lawed rea-

C l i n i ca l Nu rse s Fo r um / S a l i s b u r y a n d Hoh e nh a u sstrategies and rules of thumb to ease the burden of de-

cision making in complex circumstances. Often the way to

proceed is time compressed and unclear because of the

ambiguity created by information overload.8 To ensure

outcomes, the time-stressed professional relies on experi-

ence to facilitate the subconscious mental procedures for

processing information.8 Research specific to ED triage

decision making indicates that triage decisions are non-

analytic and based on intuition and experience.9 The an-

choring or bias that occurs during times of rapid fire triage

may later be corrected as data are gathered and analyzed

during the ongoing ED assessment and care. However,nursing assistant retakes the patients temperature and

notes it in the chart but is pulled to transport another

patient to radiology before she sees the nurse. Mrs Js care

is picked up by another physician who performs a quick

review of the chart and notes Mrs Js retake temperature of

103.88F. Unable to determine if antibiotics were started,the relieving physician seeks out Mrs. Js treating team.

However, this physician is met by another critical patient

and is consumed by this case before further investigation

into Mrs Js case can occur. Ultimately, meningitis is

confirmed with delayed administration of antibiotics.

COGNITIVE ERRORS

Errors, slips, and lapses occur all around us in emergency

care. Medical errors are human errors that often involve

cognitive activities and the inadequate processing of infor-

mation.1-3 When information is inadequate, as in Mrs Js

case, medical plans of care will be under-informed, leading

to faulty thinking, f lawed decisions, and/or errors of exe-

cution.4 An under-informed plan or a plan unknown to the

team may mean every action taken thereafter could be an

incorrect action. Recent research cites cognitive errors

how we think and what we decideto be the foundation

of most ED diagnostic errors.5-7 Cognitive errors are dis-

tinct from procedural errors and inextricably linked to the

conditions of ED care.

Anchoring, or bias, is one type of cognitive error. Bias

describes the common tendency to rely too heavily upon

one pattern or piece of information when making deci-February 2008 34:1soning or decision making.

In a team-trained setting, Mrs Js physician would have

stated the plan and the risks: This might not be a SAH,

but, with worst headache of her life and no fever, we have

to continue to rule out the SAH. If, however, a fever de-

velops, we should think about meningitis, and I need to

know immediately so we can start antibiotics. The team

briefing should be conducted with all pertinent members

of the team, including the nursing assistant, who, in Mrs Jswithout knowing the plan and updating the plan, the

anchor, once set, will result in a predictable drift toward

the bias with the potential to err.8 Precisely because

anchoring is common and specific to triage, caution must

be exercised when care is delivered under conditions of fast-

moving, incomplete, time-compressed information and

communication and when tasks are delivered in high-stress,

high-stakes arenas where volume and turnover are high.

TEAMWORK AND COGNITIVE ERROR

Engaging in formal, evidence-based, team training educates

caregivers to recognize unfolding error and provides the

skills and practice necessary to exercise the team tools and

strategies critical to trapping, managing, and/or mitigating

error and its impact.10 In operation, staff take specific ac-

tions to form or join a team where they use structured

communication to plan and problem solve; to balance

workload; and to manage and monitor care for a popula-

tion of patients over time, while performing regular event

debriefings as an ongoing mechanism for improving team

performance and care.

Knowing the plan improves outcomes.10 In one study,

after implementing an ICU Patient Daily Goals form,

the percentage of staff who knew the plan increased from

10% to 95%, and ICU length of stay was reduced by half

(2.2 to 1.1 days).11

ED teams meeting to know the plan also may improve

outcomes by conducting interdisciplinary rounds and

sharing information using the structured communication

tool of Know the Plan; Share the Plan; Review the Risks.

Verbalization of the plan alerts the team to potential risks

or bias and provides new information or the opportunity toJOURNAL OF EMERGENCY NURSING 47

fication area and shares the plan for evaluation for D. After

C l i n i ca l Nu r ses Fo rum / S a l i s b u r y a n d Hohe n ha u sthe evaluation, D is found to have acute and chronic sub-

dural hematomas and is scheduled for surgical intervention.

Biasin this case, that the patient smells of alcohol

is well known to EMS and the emergency department, and

that he always goes to detox was at work as well. How-

ever, a brief team discussion that included the correct team

members, the charge nurse, the ED physician, and the care

team, ref lected that the team knows the plan and reviewscase, was the team member who ultimately had the key

piece of clinical information. In addition, the authors

suggest that planning briefings be conducted with use of

standardized critical communication techniques such as

the Situation-Background-Assessment-Recommendation

(SBAR) method used to describe Mrs Js condition at any

patient hand-off.

KNOW THE PLAN, SHARE THE PLAN, REVIEW THE RISKS

IN ACTION

At 11 AM at a community hospital, the charge nurse takes a

call from an incoming EMS agency regarding D, a long-

time alcoholic well known to the department. Today, how-

ever, D is found down in the bushes, and after initial care

by the EMS professionals, is transported to the emergency

department awake, confused, and uncooperative. Prior to

arrival, the charge nurse pulls the treatment team together

to discuss the plan for Ds care, and using an SBAR format,

describes the plan:

Situation. Patient D is en route to the emergency

department via EMS after being found down.

Background. D has a history of alcohol abuse and is

well known to the emergency department (no assumptions

are made that the team is aware of Ds history).

Assessment. Ds behavior is different than usual, and

trauma cannot be ruled out.

Recommendation. Direct EMS is to bring D to the

resuscitation room.

The charge nurse then briefs the triage team using the

same information. As EMS enters, they note that the triage

area is overwhelmed and they move to the detoxification

area, as they have countless times in the past with D. The

triage nurse observes EMS wheeling D toward the detoxi-48 Jthe Plan, Review the Risks is a good place to start to better

manage or mitigate the potential for error in the emer-

gency department.

REFERENCES

1. Zhang J, Patel V, Johnson T. Medical error: is the solution med-ical or cognitive? J Am Med Inform Assoc 2002;9(6 Suppl 1):s75s77.

2. Kohn L, Corrigan J, Donaldson M. To err is human: buildinga safer health system. Washington: Committee on Quality ofHealth Care in America, Institute of Medicine, NationalAcademy Press; 1999.

3. Reason JT. Human error. New York: Cambridge UniversityPress; 1990.

4. Reason JT. Managing the risks of organizational accidents.Aldershot, England: Ashgate; 1997.

5. Redelmeier DA. Improving patient care. The cognitive psychol-ogy of missed diagnosis. Ann Intern Med 2005;142:115-20.

6. Croskerry P. The importance of cognitive errors in diagnosisand strategies to minimize them. Acad Med 2003;78:775-80.

7. Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med 2003;41:121-2.

8. Tversky A, Kahneman D. Judgment under uncertainty: heu-ristics and biases. Science 1974;185:1124-31.

9. Patel VL, Zhang J. Human error in naturalistic medical environ-ments: medical triage in the ED. Available at: http://cognitive.asu.edu/research/humanerror.php. Accessed December 12, 2007.

10. Agency for Healthcare Research and Quality. TeamSTEPPS:strategies and tools to enhance performance and patient safety(2006). Available at: http:www.ahrq.gov/qual/teamstepps/. AccessedJune 15, 2007.

11. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T,Haraden C. Improving communication in the ICU using dailygoals. J Crit Care 2003;18:71-5.

Clinical questions from nurses are welcome, as are names andaddresses of clinicians who are interested in answering questions.Submit to:

Susan McDaniel Hohenhaus, RN, MA, FAEN6 Willard Terrace, Wellsboro, PA 16901

570 724-1715 . shohenha@ptd.netthe risks prior to the patients arrival. In addition, sharing

the information with others who could affect the decision-

making process, such as the triage nurse, was critical to

timely and correct intervention for the patient. If the plan

is known at the time of communication, it also can be shared

with the transport team prior to the patients arrival.

Formal, structured communication tools are essential

to safe and effective emergency care. Know the Plan, ShareOURNAL OF EMERGENCY NURSING 34:1 February 2008

Know the Plan, Share the Plan, Review the Risks: A Method of Structured Communication for the Emergency Care SettingCognitive ErrorsTeamwork and Cognitive ErrorKnow the Plan, Share the Plan, Review the Risks in ActionReferences