The medical staff at the hospital started a patient on chemotherapy over a weekend. Woods describes a chemotherapy regimen he and his team analyzed at a hospital as a real-life example of how a system can be both resilient and brittle ( Cognitive Technology and Work, Vol. Since then, he's helped critique and redesign workflow plans for hospitals, the aviation industry and NASA Mission Control. He began looking at systemic strengths and weaknesses in 1979 when he was asked to help redesign control rooms to avoid future errors at Three Mile Island Nuclear Generating Station. Medical procedures in most hospitals combine factors that Woods describes as resilient - such as workers' attention to detail and makeshift rules intended to prevent errors - and brittle - including human oversight and systems that break down under unforeseen circumstances. “There's a huge opportunity to study these settings so that it supports a patient-centered approach and continuity of care,” says cognitive psychologist David Woods, PhD, professor of ergonomics at Ohio State University in Columbus. Their efforts are focused on encouraging physicians and other medical workers to think differently about how they diagnose and manage diseases. Recognizing this, psychologists are members of the teams working to mitigate such medical mistakes by designing health-care systems and practices that encourage clear communication and quality cooperation. It's the fact that physicians have a tendency to get stuck in particular modes of thinking. What accounts for these errors in physicians' reasoning? It's not incompetence or inadequate knowledge, Scott says. In fact, the correct diagnosis is either missed or delayed in 5 percent to 14 percent of urgent hospital admissions, with autopsies suggesting diagnostic error rates between 10 percent and 20 percent, according to research by Ian Scott, MD, director of internal medicine and clinical epidemiology at Princess Alexandra Hospital in Brisbane, Australia. But occasionally, they blossom into full-blown tragedies. Most medical errors are small, procedural slip-ups. Nurses would communicate instructions to each other with perfect clarity. They wouldn't have to hand off their patients to the physician working the next shift. In a perfect world, physicians would never get tired and never get stuck on the wrong solution.
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