In our opinion, medical error is an issue for cognitive science and engineering, not medicine, although the knowledge of the practice of medicine is essential for the research and prevention of medical error. This is because cognitive factors are fundamental in medical errors, as can be seen from the very definition of medical errors, the view of the healthcare system hierarchy (Figure 1), and the view of action chains (Figure 2).
The system hierarchy of medical errors.
The chain of events leading to an error.
Medical errors are human errors in healthcare. By definition,6,9
human errors are errors in human actions. Human actions are primarily cognitive activities. It is not surprising to see that human errors occur primarily due to inadequate information processing in cognitive tasks.2,9,10
Cognitive factors are critical at various levels of the healthcare system hierarchy of medical errors (Figure 1). At the lowest core level, it is individuals who trigger errors. Cognitive factors of individuals play the most critical role here.9
At the next level, errors can occur due to interactions between an individual and technology. This is an issue of human-computer interaction where cognitive properties of interactions between human and technology affect and sometimes determine human behavior.4,12
At the next level, errors can be attributed to the social dynamics of interactions between groups of people who interact with complex technology in a distributed cognitive system. This is the issue of distributed cognition and computer-supported cooperative work.1,5,11
At the next few levels up, errors can be attributed to factors of organizational structures (e.g., coordination, communications, standardization of work process), institutional functions (e.g., policies and guidelines), and national regulations. At these higher levels, cognitive factors also play some roles. Although the properties at the six levels can be to some extent studied independently, a cognitive foundation for the system is essential for a complete and in-depth understanding of medical errors.
From the view of action chains, the critical roles of cognitive factors in medical errors are also clear. Figure 2 shows the chain of events and factors that lead to an error in a system. It is clear that individuals are at the last stage of the chain, although the individuals may not be the root cause of the error. If the chain of events can be stopped at the individual’s stage through cognitive interventions, errors could be potentially prevented.
In this panel, the three participants focused on cognitive issues and presented in-depth cognitive studies of medical errors. Jiajie Zhang presented a cognitive taxonomy of medical errors; Vimla L. Patel focused on cognitive interpretation errors of medication; and Todd R. Johnson presented the importance of double experts trained in medicine and cognitive science.