Improving the Safety of Pediatric Sedation: Human Error, Technology, and Clinical Microsystems

Cognitive aids, checklists and mental models

“…Instigating and detecting change in socio‐technical systems like healthcare is difficult, due to the complexity of the systems involved, but also because of the difficulty in understanding and co‐ordinating the thoughts and plans of those in clinical teams . The content of people's heads, in terms of their understanding of the world around them and their planned actions, has been called an individual's mental model.…”

“…remind us that these aspects of clinical performance remain poorly understood, and that the creation of effective checklists and cognitive aids is hampered by this lack of understanding. In commercial aviation, checklists are routinely used for every flight, and every item on the checklist is performed – this is largely because the checklists in aviation are so well designed that they have become integrated into the pilot's workflow and are thus seen as an essential part of doing his or her job . If we are to achieve something like this level of compliance and safety with checklists in healthcare, we need to better understand how clinicians currently operate in order to design checklists and cognitive aids that are able to be meaningfully integrated into the workflow, rather than being viewed as semi‐optional add‐ons to the job that clinicians already do.…”