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? |