Systematic Review

Cognitive Biases and Errors in Radiation Therapy

Rosann Keller, MEd, R.T.(T) Amy Heath, MS, R.T.(T)

Purpose To describe common cognitive biases that can lead to radiation therapy errors. Methods A review of the literature was performed using PubMed and Cumulative Index to Nursing and Allied Health Literature. Textbooks, popular literature, and internet resources also were evaluated for their relevance to radiation therapy. Results Several common cognitive biases can lead to radiation therapy errors, including automaticity, inattentional blindness, illusion of attention, and illusion of knowledge. Discussion Cognitive biases can manifest in radiation therapy in many ways. Radiation therapists should be aware of these biases so that they can employ interventions to minimize the risk of errors. Conclusion Human error can result in treatment misadministration and near misses. One cause of human error is cognitive bias. Radiation therapists can take actions to reduce the risk of error caused by cognitive biases.

Keywords cognitive bias, radiation therapy errors, medical error, human error

rrors in radiation therapy treatments are rela- radiation therapy errors occur, and human error often is tively rare—0.18% to 0.29% per fraction, to blame. Research shows that human error is the cause according to 1 study.1 However, errors can hap- of 70% of plane wrecks, 90% of car accidents, and 90% pen at anytime during the 269 steps in the exter- of errors in the workplace.4 However, understanding Enal beam radiation therapy process, and the results can how the human brain works and how the brain affects be devastating.2 In 2010, the New York Times published the way decisions are made can minimize errors. patient stories that involved errors.3 The article described how 1 patient died after he was treated with a Methods radiation beam that was intended to be modulated, but A review of the literature was performed using the multileaf collimators failed to move into the correct PubMed and Cumulative Index to Nursing and Allied positions. The article also described a patient who Health Literature and the search terms cognitive bias, received 27 treatments to her chest wall without a radiation therapy errors, medical error, and human error. wedge, which resulted in 3 times the intended dose.3 The database searches yielded 2 articles relevant to radi- Cases of errors such as these have aspired change in the ation therapy and cognitive biases. These articles were radiation oncology community, increasing the emphasis used to focus the search to specific cognitive biases, on patient safety and quality assurance. Many radiation which were identified as applicable to radiation therapy. oncology departments have adopted changes to work- The authors found 10 articles addressing cognitive bias- flow, additional quality assurance checks, and new es and medical error. Textbooks, the American Society quality assurance tools. of Radiologic Technologists’ journals, popular litera- Despite the number of checklists and computer ture, and internet resources regarding cognitive bias and machine safeguards put in place, near misses and and the decision-making process also were consulted.

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Sources were evaluated based on their influence in determined that the number of premature deaths from radiation therapy. medical errors was more than 400 000 a year.11 Despite the increased awareness of medical errors Error Defined and their effects on patients, they continue to occur. The study of error and its causes begins with The radiation therapy process is complex and therefore defining the term. A survey of the literature found 17 prone to errors. Data from the Radiation Oncology different definitions of error, and another found 24 Incident Learning System (RO-ILS) demonstrate that definitions and a range of opinions regarding what most errors (30%) occur in the treatment planning constitutes an error.5 The Merriam-Webster Dictionary phase of the process and that most (29%) are discovered defines error as “an act or condition of ignorant or in the treatment delivery phase.12 This fact is of utmost imprudent deviation from a code of behavior” or “an importance to radiation therapists and their under- act involving an unintentional deviation from truth standing of why errors occur. or accuracy.”6 James Reason, a leading researcher in error and safety management, defines error as a generic Causes of Error term that encompasses all those occasions in which a Humans make mistakes for many reasons, including13: planned sequence of mental or physical activities fails ƒ anger issues to achieve its intended outcome and when these failures ƒ distraction cannot be attributed to the intervention of some chance ƒ lack of attention agency.7 The World Health Organization defines error ƒ personal or emotional problems as a “failure to carry out a planned action as intended or ƒ prejudices the application of an incorrect plan.”8 ƒ timidity A fundamental aspect of each definition of error Radiation therapists and other health care provid- is that the act of erring is unintentional.5 Deliberate ers often are able to recognize a mistake but might deviation from a criterion, rule, requirement, or not understand the cognitive processes that led operating procedure is a violation, which can occur to the error, which requires metacognition—the when people take shortcuts during standard operat- higher-order thinking that allows people to under- ing procedures or purposefully disregard policies and stand, analyze, and control their thought processes.14 protocols. Errors and violations increase the risk of a Metacognition requires accepting that the brain’s abil- patient safety incident, an event, or circumstance that ity to think and reason comes with natural limitations could have resulted, or has resulted, in unnecessary in mental processes.15 harm to the patient.5 A possible explanation for imperfections in cogni- tive function is the dual process theory of thought, Medical Errors which suggests that cognitive processes rely on 2 modes Medical errors have been a popular topic in health of thinking—system 1 and system 2.16 System 1 is an professional literature since the Institute of Medicine’s effortless intuitive thinking process that recognizes landmark report, published in 2000, estimated that patterns, makes assumptions and substitutions, and more than 98 000 Americans die each year because reaches conclusions and decisions quickly.17 It is auto- of medical errors.9,10 The publication led to initiatives matic, requires little or no effort, and operates with no aimed at improving patient safety from the organiza- sense of voluntary control. Researchers have theorized tional to the federal levels.10 The increased scrutiny of that humans spend about 97% of their time in intuitive medical errors also led to a more in-depth look at what thinking mode.18 System 2 is an analytical thinking constitutes a medical error and how it is reported. A process that uses knowledge, weighs data, and consid- 2013 study reviewing these processes found that the ers evidence.17 It requires effortful mental attention to Institute of Medicine’s, now called the Health and address complex problems and situations, making it a Medicine Division, estimate was low; the study instead slower and more resource-intensive process.18 System 2

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involves deliberate decision-making, problem-solving, limitations influence decision-making.24 Although and constructing thoughts in an orderly series of steps, people endeavor to make rational decisions, many fac- whereas system 1 is instinctive and often based on tors limit this ability, including the24: impressions and emotions. ƒ characteristics of the environment System 1 capabilities include the innate skills of ƒ distinct features of the cognitive system being able to perceive the world, recognize objects, (system 1 or 2) making the decision orient attention, avoid losses, and experience fear.16 ƒ type of decision or task Additional cognitive activities become automatic as Purely rational decisions require a structured and skills are learned and practiced repeatedly. Knowledge systematic approach that weighs risks and benefits. is stored in memory and accessed without effort or Decision-making also is influenced by other factors intention. System 1 impressions, feelings, and knowl- such as the decision maker’s accuracy of perceptions, edge often are used as the source for the measured knowledge, expertise, and overall intelligence. Because choices of system 2. An important aspect of system 2 is people often must make decisions with limited time that its operations require attention and are disrupted and information, they use heuristics, which can lead to when attention is withdrawn.16 cognitive biases.25 System 1 thinking is characterized by the use of Human beings have cognitive biases they are heuristics, defined as a “simple procedure that helps find unaware of and that usually are harmless. For example, adequate, often imperfect, answers to difficult ques- a cognitive bias known as the IKEA effect exists around tions” that save time and effort in daily decision-making the Swedish home furnishings store that sells ready-to- but can lead to errors.16 In simple terms, heuristics refers assemble furniture.26 Research has demonstrated that to using past experiences to learn and improve. This people who successfully complete a labor-intensive heuristic method of judging a situation or condition task such as assembling a piece of furniture place that is not intended to be scientifically accurate but higher value on their creations than they would on based on experience and common sense is also known preprocessed or preassembled items. This is a benign as a rule of thumb.19,20 Although heuristics enables people cognitive bias that demonstrates that people value the to quickly make approximate answers, it also can pro- fruits of their labor.26 duce systemic errors called cognitive biases.21 Cognitive biases can be problematic if they lead to In 1974, Tversky and Kahneman introduced the lapses in judgment, questionable decisions, and poor concept of cognitive bias, which is a “systematic error in choices. Some cognitive biases lead to hazardous cir- judgment and decision-making common to all human cumstances, dangerous decisions, and critical mistakes. beings which can be due to cognitive limitations, For example, the tendency to process information by motivational factors, and/or adaptations to natural looking for or interpreting information that is consis- environments.”22,23 Humans use their cognitive biases tent with an existing belief is called confirmation bias, to help them acquire and process information by filter- which leads people to hold on to false data or incorrect ing it through their beliefs and experiences. Cognitive information to support their beliefs.27 In the health care biases differ from other types of biases (eg, cultural, environment, confirmation bias can lead physicians to organizational, or self-interest) because they develop diagnose a patient’s disease inaccurately because they from the subconscious mental processes used for infor- tend to look for patient information that confirms their mation processing instead of emotional or intellectual initial diagnosis and dismiss information that leads to a judgments or prejudices.15 Cognitive biases are consis- different one.28 The Joint Commission in 2016 reported tent and predictable mental errors. that cognitive biases contributed to several reported Much of the research on cognitive bias comes from sentinel events (eg, wrong site surgeries, patient the field of economics. Herbert Simon, who won the falls, and diagnostic errors).29 In 2015, the National Nobel Prize in Economics in 1978, introduced the theo- Academies of Sciences, Engineering, and Medicine ry of bounded rationality, which suggests that cognitive reported that 6% to 17% of adverse events in hospitals

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resulted from diagnostic error, and that 28% of diag- Automaticity nostic error was attributed to cognitive bias.30 Research Automaticity is the “ability to perform a task by auto- indicates that medical errors are more likely to occur matic processing, independent of conscious control and and remain undetected because of cognitive bias than attention.”31 It is a psychological term referring to skilled because of mechanical and software malfunctions.17 action developed through repeated practice of an activ- Cognitive biases have a role in medical and radiation ity such as driving a car.32 Once a procedure or activity therapy errors, including: is learned, automaticity develops because individuals ƒ automaticity no longer process information in a step-by-step manner. ƒ inattentional blindness Instead, the brain’s cognitive processes automatically ƒ the illusion of attention and multitasking apply the appropriate rules to the procedure and reduce ƒ the illusion of knowledge demands on working memory.33 This process alleviates ƒ the illusion of confidence cognitive capacity to process tasks simultaneously. A ƒ the illusion of cause common example is the ability to drive a car and carry These biases, examples of how they occur in radia- on a conversation at the same time. tion therapy, and tools that can be implemented to Automaticity usually is discussed in terms of the decrease errors are summarized in Table 1. benefits it provides, such as requiring less conscious

Table 1 Summary of Cognitive Biases in Radiation Therapy Cognitive Bias Radiation Therapy Examples Tools to Decrease Cognitive Bias Automaticity Completing the time out in the computer system • Slowing down when completing checks without performing each step with the patient in a • Taking time to focus during tasks quiet, controlled environment • Thinking out loud and using a partner to double-check work Inattentional blindness Focusing on 1 part of the process or treatment, • Restructuring work environments and activities which results in oversight or errors to minimize distractions • Remembering that the radiation therapist sees a part of the process • Sharing stories of near misses and incidents Illusion of attention Letting distractions pull attention away from the • Using voicemail and inactivate notifications task at hand • Designating a quiet place to complete checks • Avoiding cross talk and distractions when possible Illusion of knowledge Planning a patient’s treatment on the incorrect side • Asking “What do I know?” and “How do I of the body and not noting that the patient was know that?” simulated feet first rather than head first • Asking staff to question themselves and others Illusion of confidence Performing a procedure that they are not ready to • Incorporating competencies into staff complete on their own performance evaluations • Using Continuing Qualifications Requirements and Maintenance of Certification programs as a guide • Continually evaluating staff education needs Illusion of cause Incorrectly believing errors always occur with certain • Investigating perceived trends types of patients or treatments • Completing root cause analysis when errors occur

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attention to complete a task or skill. However, it groups of people passing a basketball.38 One group can lead to error when an individual automatically wore white shirts, and the other wore black shirts. performs a function such as completing an item on Participants were instructed to count the number of a checklist without being aware of the task itself.34 passes made between players wearing white shirts and An example in radiation therapy might be comple- ignore the passes made between those in black shirts. tion of the time out procedure in which the activity is About halfway through the video, a person in a full- automatically completed for every treatment of every body gorilla suit walked into the scene and faced the patient. A radiation therapist could automatically indi- camera for about 9 seconds before walking out of the cate a check was done without actually performing the scene. At the end of the video, researchers asked study check or processing the information. Another example subjects how many passes the team in white shirts made is if the radiation therapist overrides a collision alarm, and then asked if they noticed the gorilla in the scene. which usually is displayed because a sheet is hanging Approximately half of the participants reported not over the table, rather than entering the treatment room seeing the gorilla and were surprised to realize they to verify that a collision will not occur. This cognitive had missed it.38 Inattentional blindness occurs when bias also might present itself as an incorrect com- an observer is engaged in an attention-demanding puted tomography simulation order. For example, the primary task and an unexpected event occurs during physician might order a head and neck scan with con- performance of that task. The unexpected event is trast, which is common for that disease site, without obvious to those not participating in the primary task, remembering that the patient has a contrast allergy. If is distinctive enough to be identified as unusual to the this oversight is not caught before the scan, the radia- observer, and occurs unexpectedly.36 Inattentional tion therapist could place an intravenous apparatus blindness means that observers do not shift their atten- unnecessarily or the patient could have an anaphylactic tion from the primary task if there is no expectation reaction if contrast is administered. that something else will happen. Slowing down, taking additional time to think, and An example of inattentional blindness in radiation thinking out loud while performing routine tasks can therapy is the treatment error publicized in the 2010 decrease the chance of an error. These pauses help the New York Times article where, during the patient’s person completing the task to be more aware of each treatment, the control panel console screen indicated action and provide a double-check process. A helpful, that the multileaf collimator was not employed and 1-second stop is useful in reducing automaticity errors. the radiation therapist failed to catch it.39 The cause STAR—stop, think, act, and review—is a useful tool of the error primarily was determined to be com- for routine tasks that can be completed without think- puter error and failure to verify the treatment plan. ing, specifically for safety critical tasks or irrevocable Although the reason the radiation therapist did not actions. By using STAR, radiation therapy errors often notice the multileaf collimator’s failure to activate at can be caught before they occur.35 the treatment console is unknown, a plausible expla- nation is that the therapist’s attention was elsewhere Inattentional Blindness on the console, perhaps observing the gantry rota- Some errors occur because people experience fail- tion. Switching attention from 1 monitor or screen to ures of awareness or miss something that is right in another can increase the possibility of error.40 Another front of them.36 The failure to notice a salient, fully vis- practical example of inattentional blindness in the ible, and unexpected object or event when attention is radiation therapy clinic is a treatment plan in which otherwise engaged is known as inattentional blindness.37 the medical dosimetrist focuses on meeting con- People tend to see only what they are focusing on to the straints but leaves the target undercovered. If the error exclusion of other relevant or important information.17 is not caught in the treatment plan review, the patient Chabris and Simons, who researched inattentional would not receive a dose high enough to reach the blindness in 1999, showed participants videos of 2 clinical goal of treatment.

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Inattentional blindness occurs because multiple accordance with the organization’s policy. While in the stimuli are competing for the brain’s attention. To patient’s chart, a text message notification popped up minimize the effect of this cognitive bias, radiation on the screen and interrupted the task workflow. After therapists first must be aware that it occurs. They then responding to the text, the resident closed the smart- can strive to restructure their work environments and phone application without completing the patient’s routine activities to minimize distractions that divert medication change order. As a result, the patient attention from the most important tasks.41 Radiation experienced debilitating effects and required an unan- therapists should remember that they see only a small ticipated surgery.43 part of all the actions happening at the time. Educating Although this case might seem extreme, as radiation staff about the radiation therapy process and shar- therapists do not enter orders into patient charts, the ing incidents and near misses that have occurred will message relates to the day-to-day activities in a radia- help to bring attention to other parts of the process. In tion therapy department. For example, during a patient addition, embracing a culture of safety in the radiation treatment, the treatment machine phone might continu- oncology department will help decrease the chance that ously ring until it is answered by the radiation therapist inattentional blindness results in an error. A culture of who also is watching to ensure that the patient remains safety encourages staff to realize that their job includes still during treatment. An urgent email notification alert the duty to improve their workplace, the processes might occur on the computer while the daily encounter with which they are involved, and communication and is being completed, or perhaps the radiation therapist understanding among team members.41 running the treatment console hears a smartphone alert of a notification. Research shows that the use of Illusion of Attention cell phones at work can increase the chance of errors The illusion of attention is the misconception that 36-fold.44 Daily distractions occur in radiation therapy the brain will be able to focus on multiple tasks without departments and result in a shift of attention from the changes in productivity or attention to detail. In reality, task at hand. This interruption in the thought process the brain can attend to only 1 cognitive task at a time. can lead to errors.45 Multitasking, which falls under the illusion of atten- Technology can be a helpful and useful tool in over- tion, is the brain’s attempt to focus on 2 tasks at once. coming mental limitations associated with cognitive The brain cannot complete 2 tasks simultaneously, but biases and in improving productivity and quality of life; rather switches its focus between tasks.4 This switching however, it should not be a substitute for cognition.46 It slows the brain’s processing ability, and takes it up to might be more appropriately used to complement the 15 minutes to regain a deep state of concentration after knowledge and skill of the radiation therapist. Once being interrupted.4 Estimates show that multitasking human cognition limits are identified, individuals can results in up to a 40% loss in productivity.42 Although use the environment and technology to mitigate the multitasking is touted as a necessary characteristic of consequences of those limits. For example, the envi- those in the health professions, research shows that it is ronment of the treatment area could be modified to not necessarily beneficial. minimize distractions to the therapists during patient Distractions and interruptions also fall under the treatment. Image-guided radiation therapy is 1 example illusion of attention. Health care professionals (espe- of technology being used to help radiation therapists— cially radiation therapists) constantly are distracted it identifies patient movement during treatment that and interrupted while performing critical tasks. A case otherwise might go unnoticed. report from the Agency of Healthcare Research and In addition to causing an increased risk of errors, the Quality demonstrates the unintended consequence illusion of attention has other consequences. When the of interruptions. The report describes the story of brain tries to focus on multiple tasks, important infor- a medical resident who was entering an order for a mation or clues can be missed.47 Interruptions decrease medication change on their smartphone, which was in the ability to concentrate on a task.44 The illusion of

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attention also might lead to incomplete tasks and a rather than on the right.49 The treatment planner used decrease in overall accuracy when the brain is trying to information they knew, which relied on the typical focus on more than 1 cognitive task. Multitasking, dis- method, and did not check whether the usual informa- ruptions, and interruptions also lead to increased stress tion was accurate. and anxiety in the workplace.48 This cognitive bias can lead to errors being missed, To minimize the effects of the illusion of attention, even during quality checks. When radiation therapists staff should be educated about the dangers and risks do not recognize that they do not completely under- associated with multitasking and interruptions. Stories stand a component of a process or machine, mistakes can be shared from recent incidents or near misses that related to these components can be missed. The key occurred in the department or from RO-ILS quarterly to overcoming the illusion of knowledge is to ask ques- reports.12 In addition, external distractions should be tions such as, “What do I know?” followed by, “How reduced when possible. Voicemail should be used on do I know that?” Radiation therapists need to question the treatment machine phones, electronic messaging themselves and others and recognize that questions programs should be closed when working on tasks, regarding patients, procedures, and equipment are not and notifications on smart devices should be turned asked to challenge authority but to ensure that noth- off. Unnecessary cross talk and unrelated discussions ing is overlooked or misunderstood. This questioning should be discouraged. Quiet, or safe, spaces should will help identify gaps in their knowledge and highlight be established for completing critical tasks such as areas where additional education is needed.4 quality assurance checks. Physical reminders can be Radiation therapists should develop a healthy sense positioned in treatment areas to discourage interrupting of self-doubt and question the reasons for their deci- radiation therapists during patient treatments. In addi- sions and actions. When decisions need to be made, tion, department workflows and procedures should be radiation therapists should base their decisions on what designed to minimize opportunities to multitask or to they know for a fact rather than on what they think they be interrupted.45 know or remember. When information is provided, radiation therapists should be moderately skeptical of its The Illusion of Knowledge accuracy and check for supporting documentation. Another cognitive bias that can lead to errors in health care is the illusion of knowledge. When indi- The Illusion of Confidence viduals have extensive experience and familiarity with The illusion of confidence causes people to overesti- equipment and tasks, they might mistakenly believe mate their qualities or skills, especially when comparing they have knowledge of all of the inner workings of themselves to others. For example, 63% of Americans the machines and processes. An example of this bias consider themselves to be of above average intelligence, is a medical event reported to the Nuclear Regulatory even though it is a statistical impossibility.4 The illusion Commission in 2007.49 A patient was scheduled to have of confidence affects how people view themselves and radiosurgery (Gamma Knife; Elekta) treatment to the how others view them. When people exude confidence, right cerebellum, but the left cerebellum was treated others interpret that as a valid signal of their abilities, instead. The explanation for the event indicated that knowledge, and accuracy. The most unskilled often during pretreatment setup and simulation, magnetic think more highly of themselves than they should, as resonance scans were acquired beginning feet first incompetence often causes overconfidence.4 In radia- rather than the standard practice of scanning a patient tion therapy, this bias might present itself as a staff head first. Treatment planning was completed using the member who has been working in the facility for 2 scan, and the planner presumed the patient had been months and has not yet completed the probationary scanned head first and did not note the right and left period but feels ready to treat patients without assis- markings on the images. This resulted in the treatment tance. However, when the staff member arrives for an target being established on the left side of the brain on-call case, he or she is not ready to clinically simulate

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and treat a patient until he or she is familiar with han- rather than drawing presumptive conclusions. It also dling the equipment alone and aware of the emergency demonstrates the importance of completing a root policies and procedures. cause analysis when errors do occur.4 In addition, To address the illusion of confidence, people need to encouraging staff to report all treatment errors, occa- become more competent in their work. The more often sions when the standard procedure is not followed, and individuals complete a task, the better they become near misses will promote a culture of safety. This data at judging their performance. In radiation therapy, will allow leadership to view trends and act when need- incorporating annual competencies for radiation ed. Sharing this data with staff should raise awareness therapists and other staff is strongly recommended.50,51 of the causes of errors and assist in preventing similar The American Registry of Radiologic Technologists’ errors in the future.40 Continuing Qualifications Requirements ensure that radiation therapists continue to be educated in areas Conclusion where they might lack exposure.52 Radiation oncologists Motivational speaker Zig Ziglar said, “The first have similar mandates, Maintenance of Certification, step in solving a problem is to recognize that it does from the American Board of Radiology.53 By imple- exist.”55 Radiation therapists must be willing to admit menting routine competency exercises and a method of to themselves and others that they make mistakes. continually evaluating education needs, staff in radia- Interventions then can be employed to minimize the tion therapy departments will become better evaluators risk of errors. Because errors can be attributed to cogni- of their own competence and their own confidence. tive biases, radiation therapists must become skilled at cognitive debiasing, identifying bias in their decision- Illusion of Cause making, and adopting interventions to overcome The illusion of cause is the cognitive bias that tricks biases.56 It also might be helpful for radiation therapists the brain into seeing patterns in randomness. For to be more deliberate in their decision-making and example, people who have arthritis often complain of actions. Deliberation outperforms intuition when indi- flare-ups when the weather is bad. Although no scien- viduals have conscious access to all necessary data.46 tific basis for this phenomenon exists, the illusion of Radiation therapists also should keep in mind that the cause makes the brain interpret an event as a predictor brain’s ability to fill in voids in perception can cause for all future events.4 In radiation therapy, a provider errors and that a second look or asking a co-worker to seems to frequently rewrite the treatment planning double-check work can minimize the risk of error. computed tomography orders or is regularly late sign- Without reflection, intuition can lead people to ing notes in electronic medical records. It might seem believe that they know more than they do, that they that all last minute add-on patients happen on Friday pay more attention than they do, and that their com- afternoon, or that the saddest patient cases occur dur- petence is equivalent to their confidence. Although it ing the holidays. However, the brain determines a is impossible to eliminate cognitive biases completely, pattern from 1 occurrence. being aware of them can minimize their effects in In a 2015 study, researchers from the University patient care. of Washington investigated a common theme related to the illusion of cause—errors and emergency treat- ments.54 Although many radiation therapists believe Rosann Keller, MEd, R.T.(T), is radiation therapist and that errors are more likely to occur during emergent certified tumor registrar in Detroit, Michigan, and former treatments because of rushed timelines, decreased assistant professor of radiation therapy technology at Wayne staff, and modified procedures, the researchers found State University in Detroit. that fewer error reports were submitted for emergency Amy Heath, MS, R.T.(T), is radiation therapy education treatments than for nonemergency treatments.54 This program manager at the University of Wisconsin Hospital example shows the value of studying cause and effect and Clinics in Madison, Wisconsin, and adjunct faculty

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for the radiation therapy program at the University of Product. https://www.astro.org/ASTRO/media/ASTRO Wisconsin-La Crosse. /Patient%20Care%20and%20Research/PDFs/ROILS-Q1-Q2 _2018_Report.pdf. Published 2019. Accessed April 16, 2019. Received November 7, 2019; accepted after revision 13. Piatelli-Palmarini M. Inevitable Illusions: How Mistakes of Reason December 29, 2019. Rule Our Minds. Wiley; 1994. Reprint requests may be mailed to the American Society 14. Metacognition. Dictionary website. https://www.dictionary of Radiologic Technologists, Publications Department, .com/browse/metacognition. Accessed April 16, 2019. 15000 Central Ave SE, Albuquerque, NM 87123-3909, or 15. Heuer RJ Jr. Psychology of Intelligence Analysis. Central for the Study of Intelligence: Central Intelligence Agency. 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