Decision-making under pressure: medical errors in uncertain and dynamic environments

Abstract

This paper provides a narrative overview of the literature concerning clinical decision-making processes when staff come under pressure, particularly in uncertain, dynamic and emergency situations. Studies between 1980 and 2015 were analysed using a six-phase thematic analysis framework to achieve an in-depth understanding of the complex origins of medical errors that occur when people and systems are under pressure and how work pressure affects clinical performance and patient outcomes. Literature searches were conducted using a Summons Search Service platform; search criteria included a variety of methodologies, resulting in the identification of 95 papers relevant to the present review. Six themes emerged in the present narrative review using thematic analysis: organisational systems, workload, time pressure, teamwork, individual human factors and case complexity. This analysis highlights that clinical outcomes in emergency situations are the result of a variety of interconnecting factors. These factors may affect the ability of clinical staff in emergency situations to provide quality, safe care in a timely manner. The challenge for researchers is to build the body of knowledge concerning the safe management of patients, particularly where clinicians are working under pressure. This understanding is important for developing pathways that optimise clinical decision making in uncertain and dynamic environments. Emergency departments (EDs) are characterised by high complexity, high throughput and greater uncertainty compared with routine hospital wards or out-patient situations, and the ED is therefore prone to unpredictable workflows and non-replicable conditions when presented with unique and complex cases. Clinical decision making can be affected by pressures with complex origins, including organisational systems, workload, time constraints, teamwork, human factors and case complexity. Interactions between these factors at different levels of the decision-making process can increase the complexity of problems and the resulting decisions to be made. The findings of the present study provide further evidence that consideration of medical errors should be seen primarily from a 'whole-of-system' perspective rather than as being primarily the responsibility of individuals. Although there are strategies in place in healthcare organisations to eliminate errors, they still occur. In order to achieve a better understanding of medical errors in clinical practice in times of uncertainty, it is necessary to identify how diverse pressures can affect clinical decisions, and how these interact to influence clinical outcomes.

Collaboration and Satisfaction About Care Decisions in Team questionnaire—Psychometric testing of the Norwegian version, and hospital healthcare personnel perceptions across hospital units

“…By the time the patient's physician arrives, the dedicated nurse has often moved on to attend to the next patient (Krogstad, Lindahl, Saastad, & Hafstad, ). The ER is an area of the hospital that is characterized by high complexity, high throughput and high uncertainty and patient care decisions can be affected by the pressures imposed by the high workload and ineffective teamwork (Zavala, Day, Plummer, & Bamford‐Wade, ). Team‐based care and TDM are of great importance to ensure quality patient care, in ERs as in other hospital units (Reader, ).…”

“…They should be included because they might have valuable information about their own health condition (WHO, ). Patient participation may contribute to help healthcare personnel make the right decisions and to minimize decision errors (Zavala et al, ). Although healthcare personnel are striving for patient participation in decision‐making to increase the quality of care and patient‐centred outcomes in the ER (Grudzen, Anderson, Carpenter, & Hess, ), many patients cannot participate in decisions because of their critical condition (Joseph‐Williams, Elwyn, & Edwards, ).…”

Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision‐making

“…However, heuristics, which are useful mental short cuts adopted to solve a problem, may fail to accurately assess a complex dilemma and result in cognitive bias or cognitive disposition to respond (CDR) . This, I suggest, can subsequently cause missteps in the reasoning process, with unanticipated yet burdensome morbidity outcomes …”

“…It is harder to activate and is mostly on standby, while System 1 idles fluently and automatically. The problem is that slow thinking is the rational deliberative thought required for extremely complex multifaceted decisions involved in clinical prognosticating, ethical reasoning and when there is dissent between clinicians and or families …”

“…While many experiential biases potentially lead to questionable outcomes in clinical decision‐making, most notable for the scope of this proposal relating to ethical reasoning are: availability, anchoring, association, pervasive optimistic and ‘sunk cost’ bias (Table ).…”