There are thousands of injuries and deaths that occur needlessly each year in hospitals nationwide, including in Maryland. These are due to surprisingly careless mistakes, some made by surgeon error and some by the mistakes of other medical personnel. A concept that attempts to explain the cause of many of these errors is emerging.
That phenomenon is called "cognitive bias." It occurs in the medical malpractice context when a surgeon or other hospital employee does not carefully examine the identity of a medicine or substance because of a kind of "blind" reliance on the expected competence of the nurse or other assistant who handed it over. For example, recently, an elderly woman entered a hospital for a surgical procedure relating to a severe back injury.
The surgeon needed to view the spine prior to performing the surgery. He requested a specific dye, but the nurse received something else from the pharmacy because the requested dye was out of stock. The nurse handed it to the surgeon, telling him it was "what we have." The surgeon looked at it and injected it twice into the patient.
The patient died the next day. The dye was clearly marked as dangerous for use in the spine, but the surgeon's mind did not register the warning. He saw, in a sense, what he wanted to see because he relied basically on the prior competence of the nurse. That may be an innocuous phenomenon in some settings, but it can be deadly in a hospital operating room.
The case is now in litigation for medical malpractice. In Maryland and elsewhere, cognitive bias is behind many instances of avoidable surgeon error and hospital mistakes. Some hospitals have recognized the problem and are implementing written and electronic procedures that have layers of confirmation of the accuracy of the details of a key procedure. These new safeguards are meant to prevent medical personnel from making the medical errors that have caused so many avoidable tragedies in the past.
