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Training to minimize errors in MEdical Decision making by Mind Map: Training to minimize errors in
MEdical Decision making
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Training to minimize errors in MEdical Decision making

Keynote opening lecture of #AMEE2010, Glasgow, Education conference by Itiel Dror


The human element

stands at the heart of error in medical decision making

perception of information



Must deal with medical decision making error through understanding of human cognition and the medical environment

Not an issue of public policy

"Medicare pulling plug for errors

State fines 9 hospitals USA

Third wrong-sides brains surgery - fined

The medical environment is prone to error - PROBLEM -

Time pressure

Quantity and quality of information

Risk taking

Cognitive systems involved, Analytic, Trained in medical education, Intuitive / Experiential, Not trained in medical education


distributed cognition

lack of continuity


New node

Human cognition

Prone to errors, due to cognitive architecture

Experts are more susceptable to this(!)

The Pardox of human expertise: Why experts can get it wrong

"The mind is not a camera" (from "perception is Far from Perfection") -

lost less of the slide

Some examples are shown on how our brain can fool us


e.g. Gorilla test,, Through twitter alternative suggestion (@salmaansana):

The way forward

Training to reduce errors

training should target specific causes of errors, For example, right patient?, right drug?, right dose?, right time?, patient safety training, checklists

Something different needed, Training for error recovery, - slide missed -, proposed methods, interactive videos, Gaming, engaging, highly motivational, Assessment, through gaming, Recommandation to combine assesment and learning, Error recovery, Training that understands and acknowledges human cognition, expertise, and the medical environment, Good training in error recovery will, in the short term, result in fixing some errors (and diminish the consequences of many others)