Cognitive Biases and Errors in Radiation Therapy

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. 128 asrt.org/publications Systematic Review Keller, Heath 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 anger issues to achieve its intended outcome and when these failures distraction cannot be attributed to the intervention of some chance lack of attention agency.7 The World Health Organization defines error personal or emotional problems as a “failure to carry out a planned action as intended or prejudices the application of an incorrect plan.”8 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 cognitive 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 RADIATION THERAPIST, Fall 2020, Volume 29, Number 2 129 Systematic Review Cognitive Biases and Errors in Radiation Therapy 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. characteristics of the environment System 1 capabilities include the innate skills of 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 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

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