The potentially devastating consequences of accidents means the NHS has a clear mandate to prioritise medical error reduction, whilst utilising energy, attention, and creativity towards delivering high-performance, high-confidence healthcare (DoH, 2000). The application of psychological theories of human action and error has an important part to play within this endeavour, not least because they exceed the merely descriptive, instead combining cognitive, affective and behavioural considerations to provide more integrated understandings of patient safety issues (Parker & Lawton, 2006). Indeed, according to Zhang and colleagues (2002, p.75) “medical error is primarily an issue for cognitive scienceâ€¦not for medicine.”
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Psychology has a long and distinguished tradition of discerning the nature and sources of human error (e.g., Broadbent, 1958; Rasmussen, 1990; Reason, 2000) and, in terms of patient safety, researchers are increasing recognising that appreciating such mechanisms is a vital prerequisite for devising suitable remediation (Parker & Lawton, 2003, 2006). One important distinction in this regard is between the concept of slips/lapses (a sound plan, poorly executed), mistakes (an inappropriate plan, correctly implemented) and violations (a deliberate deviation from recommended practice). In contrast to the latter, which are generally intentional, slips/lapses and mistakes are primarily driven by failures in cognitive processing, and are therefore amenable to interventions based on knowledge acquisition, skills enhancement, and information provision (Lawton, 1998). It is these particular principles that form the basis of this review.
Error in the health industry is ubiquitous, and the capacity for mistakes within even routine medical procedures is considerable (Bogner, 2004a). For example, a sobering compilation by Van Cott (1994) identified medication/anesthesia administration, laboratory testing, blood transfusions, diagnostic screening and the operation of medical technology as regular candidates for both incident reporting and malpractice claims. However, while healthcare providers conventionally emphasised refining technical proficiencies, appreciating the intricacy of staff’s cognitive performance (and developing strategies to augment it) has a greater likelihood of enhancing safety (Hudson, 2003; Looseley et al., 2009; Zhang et al., 2004).
According to Casey (1993, p.9) the individual as an independent system (i.e., unhampered by any kind of technology) is actually remarkably reliable; conversely, error likelihood is amplified by “incompatibilities between the characteristics of peopleâ€¦and the characteristics of the things we create and use.” Applying psychological principles within healthcare systems has shown that working conditions, conventions, and procedures can be tailored to complement what we know about human behaviour, and that this wisdom can be utilised in a corrective way. Psychological research within other high-risk industries demonstrates that while mental operations often function beyond voluntary control, it is both possible and desirable to modify conditions in which staff perform (Green, 2004; Raab et al., 2006; Wilf-Miron et al., 2003). For example, McCulloch and colleagues (2009) designed an intervention derived from aviation-style ‘Crew Resource Management’ coaching, implemented in the operating theatre of a UK teaching hospital. The programme, comprised of teamwork skills, safety attitudes and performance training, was associated with significant reductions in operative technical errors and non-operative procedural errors. Similar results have been reported by Haller et al. (2008), who found that aviation-style training contributed to a significant improvement in multidisciplinary teamwork and organisational safety culture.
In contrast, Rogers and colleagues (2004) advocate designing nurses’ work-shift cycles in concordance with current psychological knowledge about the impact of sleep disruption on acuity and performance, whereas Laschinger and Finegan (2005) suggest using empowerment principles derived from organisational psychology (e.g., workplace trust, respect, and justice) to motivate staff to lend their energy and expertise to prioritising patient safety. In more cognitive terms, Valenstein (2008) used tenets from the psychology of perception (e.g., optimized information density, ease of transfer, maximized fidelity/speed) to devise strategies for pathologists to format surgical reports in a manner that communicates most effectively and limits the chance of misinterpretation. Similarly, Shojania (2002) suggests that research inspired both by cognitive psychology and accident investigation within other industries provides the raw materials for predicting errors, recording critical incidents, and reacting to them in a proactive, non-punitive manner.
According to Reason (1994, p.ix) “blaming fallible individualsâ€¦is universal, natural, emotionally satisfying and legallyâ€¦convenient. Unfortunately it has little or no remedial value  .” One of the most basic principles of error management – that transitory mental states like preoccupation, disorientation, and distraction are mostly inadvertent and hugely variable – has been guided by psychological research into human performance that emphasise the necessity of systems-based approaches which identify latent organisational failures in addition to active individual errors (Bogner, 2004b). Medical systems incorporate vast, intricate arrays of disparate and semi-autonomous components, operating within variable, diffused and unpredictable circumstances. Indeed, according to Van Cott (1994, p.55) “of all sociotechnical systems [healthcare delivery]â€¦is the largest, most complex, most costly and, in some respects, the most unique.” Furthermore, it is grounded within a person-centred, person-driven system, with human operators its most ubiquitous and valuable element. Using the science of human thought and behaviour to enhance and refine human performance therefore appears a profitable way of pursuing healthcare quality and safety.
Poor adherence to self-administered medical interventions is a pervasive, wide-ranging problem which compromises the efficacy of prescribed healthcare, squanders therapeutic resources and, most seriously, potentially endangers patient well-being (Park et al., 2004; Roter et al., 1998; Thomas, 2009). Research suggests that at least 50% of patients fail to receive the full benefit of therapeutic recommendations (e.g., preventative practices, medication regimens, lifestyle modification) due to inadequate observance of medical advice (Morisky et al., 2009), whereas up to 30% use drug prescriptions in a manner that poses a serious risk to health (Schmittdiel et al., 2008). Both conceptually and methodologically, medical compliance raises complex issues for patients and providers, meaning that a careful consideration of the problem is necessary before significant and meaningful enhancements in adherence (and consequent health status) can be achieved (Haynes et al., 1996).
An important contribution from psychology for precluding self-care errors is a systematic understanding of the cognitive changes that may provoke them. Specifically, memory and comprehension deficits are a manifest cause of poor compliance (Park et al., 2004). This is particularly prevalent in terms of age-related cognitive decline, although even younger adults with high cognitive functioning are not exempt from the kind of intellective impairments that thwart the ability to attend to one’s medical needs. This is consistent with the well-established finding that declines in cognitive ability are gradual, continuous and linear across the adult lifespan (Baltes & Lindenberger, 1997). For example, medical errors in elderly individuals may be partly generated by deteriorations in processing speed, working memory and long-term recall (Davis et al., 2010; Hayes et al., 2009; Stoehr et al., 2008), which impede the ability to both encode and retrieve unfamiliar medical regimens, or to incorporate them into a treatment plan compatible with daily routine. In contrast, deficits in time-based prospective memory (Woods et al., 2009), working memory (Smith, 2007), and source memory (Park et al., 2004) can compromise the capacity of younger adults to adequately self-manage medical recommendations, an effect exacerbated amongst those who are inexperienced healthcare consumers (Park, 1999), or who are subject to excessive distraction, stress or fatigue (Stilley et al., 2010). Similarly, the ‘illusion of truth effect’, whereby statement repetition heightens perceived truth (Begg, 1992), is a powerful memory distortion to which adults of all ages are susceptible, and which can be dangerous in the medical realm if false information is remembered as true (for example, a conscientious clinician who repeatedly extols the futility of herbal remedies for diabetes may risk her patient paradoxically recalling herbal remedies as advantageous, due to failures in context-dependent memory: Park et al., 2004).
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In response to this, psychological research has informed a range of interventions to reduce medical self-management errors. For example, providing older adults with novel information in written form promotes assimilation through decreasing burdens on working memory (Tsai, 2006), whereas comprehension and decision-making can be enhanced through environmental supports like audiovisual materials, telephone instruction, and follow-up sessions with a healthcare provider (Myers & Midence, 1998). Cognitive resources may also be supplemented with contextual supports, which help consolidate memory for health communications at the time of encoding and retrieval for patients of all ages. For example, simplified treatment regimens, or those that are conveniently tailored to daily habits (Smith, 2007), medication organizers and ‘reminder’ pill packaging/prescription refills (Petersen et al., 2007), supportive home visits (Kripalani et al., 2007), behavioural contracting and modelling (Christensen & Johnson, 2002), text-message prompts (Matsui, 2009), and electronic beepers (Kalichman, 2005), have all been shown to consistently enhance treatment adherence, with subsequent improvements in treatment outcomes. A considerable benefit of all these strategies is that they employ resources that are readily accessible within clinical settings.
According to Rasmussen (1994, p.392) patient safety is “a frontier for change”. An important aspect of this process is effective transfer of research themes into clinical practice. While psychological approaches have facilitated enhanced performance and learning at both organisational and individual levels, ensuring such improvements remain sustained and intentional is a complex task. Successful diffusion of evidence-based interventions to real-world applications requires prudent planning, implementation, and evaluation in order that healthcare quality can be constantly revised and refined. For example, inadequate understandings of the theoretical processes implicated in behaviour change means evidence-based guidelines are often poorly implemented within medical settings (Michie et al., 2005), while the intense rapidity and intricacy of change within healthcare means conflict can exist between academics seeking to develop and refine theories, and the more immediate, practical need of practitioners seeking information on which to develop interventions.
In this respect, a promising area for development is increased multidisciplinary working, not only in terms of partnerships between practitioners and psychologists, but in the active involvement and recruitment of patients themselves (DoH, 2005). Collaboration can be seen as “the coming together of diverse interests and people to achieve a common purpose via interactionsâ€¦and coordination of activities”(Jassawalla & Sashittal, 1998, p.239), with such alliances potentially facilitating the merging of science and practice through enhanced information-sharing, formulating accessible and meaningful research questions, developing shared visions of patient safety, and designing/disseminating interventions using appropriate materials and methods for practitioner/patient needs. As Carr and Kemmis (1996, p.165) observe, within this aspiration is:
“Improvement of a practice of some kindâ€¦improvement of the understanding of a practiceâ€¦andâ€¦the improvement of the situation in which the practice takes placeâ€¦Those involved in the practice being considered are to be involved inâ€¦all its aspects of planning, acting, observing and reflecting for optimum results.”
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