1. Keynote opening lecture of #AMEE2010, Glasgow, Education conference by Itiel Dror
1.1. Link
1.2. [email protected]
2. The human element
2.1. stands at the heart of error in medical decision making
2.1.1. perception of information
2.1.2. interpretation
2.1.3. judgement
2.2. Must deal with medical decision making error through understanding of human cognition and the medical environment
2.3. Not an issue of public policy
2.3.1. "Medicare pulling plug for errors
2.3.2. State fines 9 hospitals USA
2.3.3. Third wrong-sides brains surgery - fined
3. The medical environment is prone to error - PROBLEM -
3.1. Time pressure
3.1.1. Quantity and quality of information
3.1.2. Risk taking
3.1.3. Cognitive systems involved
3.1.3.1. Analytic
3.1.3.1.1. Trained in medical education
3.1.3.2. Intuitive / Experiential
3.1.3.2.1. Not trained in medical education
3.2. Piecemeal
3.2.1. distributed cognition
3.2.2. lack of continuity
3.3. Technology
3.3.1. New node
4. Human cognition
4.1. Prone to errors, due to cognitive architecture
4.1.1. Experts are more susceptable to this(!)
4.1.2. The Pardox of human expertise: Why experts can get it wrong
4.2. "The mind is not a camera" (from "perception is Far from Perfection") -
4.3. lost less of the slide
4.4. Some examples are shown on how our brain can fool us
4.4.1. intertaining
4.4.2. e.g. Gorilla test
4.4.2.1. http://tinyurl.com/37sj9d7
4.4.2.2. Through twitter alternative suggestion (@salmaansana): http://tinyurl.com/32nr84j
5. The way forward
5.1. Training to reduce errors
5.1.1. training should target specific causes of errors
5.1.1.1. For example
5.1.1.1.1. right patient?
5.1.1.1.2. right drug?
5.1.1.1.3. right dose?
5.1.1.1.4. right time?
5.1.1.2. patient safety training
5.1.1.3. checklists
5.1.2. Something different needed
5.1.2.1. Training for error recovery
5.1.2.1.1. - slide missed -
5.1.2.1.2. proposed methods
5.1.2.1.3. Assessment
5.1.2.1.4. Error recovery