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Why Smart AAPM and COMP Members Do Dumb Things

A Rubinstein1*, D Brown2*, T Pawlicki3*, S Evans4*, (1) McGovern Medical School, Houston, TX, (2) University of California, San Diego, La Jolla, CA, (3) UC San Diego, La Jolla, CA, (4) Yale University, New Haven, CT


(Tuesday, 7/14/2020) 4:30 PM - 5:30 PM [Eastern Time (GMT-4)]

Room: Track 6

Medical error involves not only failure to carry out intended actions, but also errors in judgment, which are heavily influenced by our manner of thinking. Major radiotherapy, imaging, and diagnostic errors, such as in the Glasgow incident or the Detroit incident, have identified cognitive bias as a contributor to the incident, and the Joint Commission has identified cognitive bias as a major contributor to medical error. The field of cognitive science seeks to better understand how we process information and make decisions. This session will serve to explore how heuristics and type 1 thinking (pattern recognition) tend to govern the day, how cognitive biases shape our decisions, and what tools (like metacognition, cognitive debiasing) can be used to help mitigate the influence of these biases.

This session will explore how inattentional blindness, availability bias, and representativeness bias can mislead us in both imaging and therapy. This session will also help the learner gain an appreciation for just how common bias is in all of our every day decisions.

Learning Objectives:
1. Describe the roles cognitive bias has played in radiotherapy and imaging errors, and understand the prevalence of cognitive error in every day personal and professional life
2. Utilize bias terminology to accurately describe biases commonly encountered in the clinical decision making workflow
3. Practice debiasing strategies such as “considerate the opposite” “prospective hindsight,” or “red teams” to help improve decision making quality

Funding Support, Disclosures, and Conflict of Interest: Drs. Brown and Pawlicki are founding partners of Dr. Brown receives lecture honoraria from Varian Medical Systems. Dr. Evans receives honoraria from Clarity Patient Safety Organization, for her work with the Radiation Oncology Health advisory committee, the analysis arm of the Radiation Oncology Incident Learning System.



Quality Assurance, Decision Theory, Systematic Errors


Education: Evaluation

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