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The historical tendency to view medicine as both an art and a science may have contributed to a disinclination among clinicians towards cognitive science. In particular, this has had an impact on the approach towards the diagnostic process which is a barometer of clinical decision-making behaviour and is increasingly seen as a yardstick of clinician calibration and performance. The process itself is more complicated and complex than was previously imagined, with multiple variables that are difficult to predict, are interactive, and show nonlinearity. They appear to characterise a complex adaptive system. Many aspects of the diagnostic process, including the psychophysics of signal detection and discrimination, ergonomics, probability theory, decision analysis, factor analysis, causal analysis and more recent developments in judgement and decision-making (JDM), especially including the domain of heuristics and cognitive and affective biases, appear fundamental to a good understanding of it. A preliminary analysis of factors such as manifestness of illness and others that may impede clinicians' awareness and understanding of these issues is proposed here. It seems essential that medical trainees be explicitly and systematically exposed to specific areas of cognitive science during the undergraduate curriculum, and learn to incorporate them into clinical reasoning and decision-making. Importantly, this understanding is needed for the development of cognitive bias mitigation and improved calibration of JDM in clinical practice.

IntroductionAlthough patient safety has improved steadily, harm remains a substantial global challenge. Additionally, safety needs to be ensured not only in hospitals but also across the continuum of care. Better understanding of the complex cognitive factors influencing health care-related decisions and organizational cultures could lead to more rational approaches, and thereby to further improvement.HypothesisA model integrating the concepts underlying Reason's Swiss cheese theory and the cognitive-affective biases plus cascade could advance the understanding of cognitive-affective processes that underlie decisions and organizational cultures across the continuum of care.MethodsThematic analysis, qualitative information from several sources being used to support argumentation.DiscussionComplex covert cognitive phenomena underlie decisions influencing health care. In the integrated model, the Swiss cheese slices represent dynamic cognitive-affective (mental) gates: Reason's successive layers of defence. Like firewalls and antivirus programs, cognitive-affective gates normally allow the passage of rational decisions but block or counter unsounds ones. Gates can be breached (ie, holes created) at one or more levels of organizations, teams, and individuals, by (1) any element of cognitive-affective biases plus (conflicts of interest and cognitive biases being the best studied) and (2) other potential error-provoking factors. Conversely, flawed decisions can be blocked and consequences minimized; for example, by addressing cognitive biases plus and error-provoking factors, and being constantly mindful. Informed shared decision making is a neglected but critical layer of defence (cognitive-affective gate). The integrated model can be custom tailored to specific situations, and the underlying principles applied to all methods for improving safety. The model may also provide a framework for developing and evaluating strategies to optimize organizational cultures and decisions.LimitationsThe concept is abstract, the model is virtual, and the best supportive evidence is qualitative and indirect.ConclusionsThe proposed model may help enhance rational decision making across the continuum of care, thereby improving patient safety globally.

Abstract Background The scope of practice of paramedics in Canada has steadily evolved to include increasingly complex interventions in the prehospital setting, which likely have repercussions on clinical outcome and patient safety. Clinical decision making has been evaluated in several health professions, but there is a paucity of work in this area on paramedics. This study will utilize the Delphi technique to establish consensus on the most important instances of paramedic clinical decision making during high acuity emergency calls, as they relate to clinical outcome and patient safety. Methods and design Participants in this multi-round survey study will be paramedic leaders and emergency medical services medical directors/physicians from across Canada. In the first round, participants will identify instances of clinical decision making they feel are important for patient outcome and safety. On the second round, the panel will rank each instance of clinical decision making in terms of its importance. On the third and potentially fourth round, participants will have the opportunity to revise the ranking they assigned to each instance of clinical decision making. Consensus will be considered achieved for the most important instances if 80% of the panel ranks it as important or extremely important. The most important instances of clinical decision making will be plotted on a process analysis map. Discussion The process analysis map that results from this Delphi study will enable the gaps in research, knowledge and practice to be identified.

A letter to the editor is presented in response to the article "The Vanishing Lung" by N.N. Shah, R. Bhargava and Z. Ahmed published in a previous issue.

This case describes a 45-year-old woman with significant respiratory distress secondary to a left-sided pleural effusion that mandated an urgent thoracentesis. An adverse event occurred when the physician performed the procedure on the incorrect side of the patient. Results of the incident investigation followed by a discussion of medical errors models, common errors types, human factors considerations, and conditions that contribute to error are presented. Pertinent case-specific and general concepts of a system approach to reduce this type of medical error are discussed, and educational recommendations are offered.