1. Observer without knowledge or experience with HFE concepts

2. Authority Effect—we tend to do what authorities tell us to do, trusting that unintended consequences have been considered.

3. Financial measures frequently change, consuming leadership attention

4. Cost silos obscure how costs relate to each other

5. Halo bias-assigning the term “quality” or “patient safety” to a process may reduce challenging the science behind it. Assumption: Must be good since termed “quality” or “safety” metric. Logic becomes circular and self-perpetuating.

6. Failing to recognize how one intervention in isolation may be though to improve quality (e.g. creating a Best Practice Alert on electronic medical record or BPA). However when inserted into the system workflow, may lessen quality at individule and at organizational multi-user level due to increase cognitive load and thought derailment.

Technology insertion capabilities raise new ethical issues.

a. Does an authority have sufficient certainty that the benefit of demanding attention (e.g. BPA) outweighs the risk of disrupting the current existing clinical cognitive thought flow process?

b. Might technology disruption of cognitive thought flow affect quality of thinking that follows, such as differential diagnosis or treatment plan?