Wrongful Death Case Highlights Issue of Cognitive Bias

Wrongful Death Case Highlights Issue of Cognitive Bias

As much as we might want eliminate every risk of a deadly mistake being made in the delivery of medical care or the performance of a surgical operation, the fact is that medical professionals are only human.

That does not mean that we can’t and shouldn’t do all we can to create systems aimed at reducing the chance of errors due to carelessness. Indeed, it is through such systems that patients in Missouri can be assured that hospitals and the medical professionals they employ are doing all they can for patient safety. And then, when mistakes are made, it should be easier to hold those who are responsible accountable for the serious injury or wrongful death that occurs.

The reality of one form of particular medical error is something that recently got put under the spotlight. An article in The Boston Globe tells the story of a 74-year-old woman who went to Tufts Medical Center for what was supposed to a be a brief procedure to relieve some back injury symptoms.

As part of the procedure the surgeon called for the use of a special dye. But the particular product wasn’t available so an alternative was provided. Unfortunately, the dye supplied isn’t safe for use in the spine and the label says so. But the doctor didn’t notice the warning. He used the dye and the patient died after enduring severe pain and seizures.

The mistake has since been chalked up to “cognitive bias” on the doctor’s part. That is, despite what the label said, the surgeon saw what he expected to see — the dye he ordered.

How often cognitive bias may contribute to surgical errors is difficult to quantify, but as this case shows, it can happen. It is considered to be an even greater problem when a failure to diagnose is suspected. Indeed, research published in the Journal of the Association of American Medical Colleges indicates that diagnoses are often based on a doctor’s experience. That can be limited and result in diagnosis errors that can ultimately prove deadly. It’s one reason why second opinions are commonly recommended.

The sons of the victim in this case are suing the hospital, but the hospital’s insurer is reportedly denying any negligence. That’s despite the surgeon’s reported acknowledgement of his mistake and subsequent changes in hospital practices to reduce such mistakes in the future.

Source: The Boston Globe, “Surgical error at Tufts prompts widespread changes,” Liz Kowalczyk, Aug. 31, 2014

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