Consider this scenario. An adventure traveler begins his trek to a remote village in the Andes. Upon arriving at the airport, he rents a car and begins his journey on winding roads to the village. After 90 minutes of driving, he encounters an intersection with a traffic light. Upon seeing the bottom of the light glowing brightly, he continues through the intersection.
Suddenly, his car is knocked sideways by an automobile that crashes into his front passenger side door. No one is injured but both cars are severely damaged. Figuring his “attacker” ran a red light as his light was surely green, he jumps out to accuse the other driver of reckless driving. Upon further investigation, our traveler learns that in this part of the country, traffic lights are constructed differently than in the United States. Although a red light means stop and a green light means go, green lights are placed at the top of a traffic light while red lights are at the bottom, completely opposite what is followed in the U.S. and most of the world.
Who is at fault here? I am pretty sure our traveler saw the bottom light as red but his brain processed it as green, meaning go. In every other situation encountered by this traveler, a glowing light at the bottom of a traffic light was green, and it meant “go.” For human beings to navigate the world efficiently, we generalize our surroundings.
Inference Rather Than Analysis
The effort required to analyze each situation requires too much brain processing and would cripple our ability to do things. Therefore, when we encounter situations that are familiar to us, we infer much of the situation, using only a limited amount of the reality as a template for what we are seeing and experiencing. Only when we encounter completely novel situations, do we dial back our inference and concentrate on the activities in front of us. Yet, even then, we do a significant amount of inference to make efficient our interpretation of the situation.
Workflow and process redesign must consider not only the existing patterns of care delivery and the ways to make them better, but also the inherent way human beings process their environment. As noted above, inferring the environment is critical to our maneuvering through our daily lives. A workflow that does not consider the impact of inference on the actions of human experts can easily lead to medical errors.
As organizations work at deploying health information technology and deliver clinical transformation through redesigned workflows, they need to recognize the basis for many of the errors we, as human beings, make in our everyday lives. By recognizing our limitations and designing around them, we can fully reap the safety benefits of health information technology in our delivery of patient care.
Excerpts from: Seeing Is Not Believing. PSQH, March/April, 2011