Marjorie Stiegler, M.D. and Sara Goldhaber-Fiebert, M.D.
Instructor Guide for Understanding and Preventing Cognitive Errors in
Healthcare Video
Resources
1. Trigger Video of Understanding and Preventing Cognitive Errors in Healthcare
2. Powerpoint of Key Concepts
3. “Illness Script” PDF
4. Instructor Guide including references for further reading
Background
This brief animated video, filmed at the Stanford University School of Medicine’s Immersive
Learning as a collaboration between Stanford and UNC physicians, describes some
introductory concepts about medical decision making errors and strategies to avoid them. The
impetus for creating it was the recent focus in safety literature about diagnostic delay and
misdiagnosis as a major sphere of medical error, and the small but growing number of
manuscripts dedicated to exploring cognition and medical decisions. This trigger video is a first
step in addressing these concepts in an accessible way for learners and clinical teachers, and
serves as a springboard for discussion in many educational settings.
Purpose
Provide a venue for talking about the principles of decision making and cognition, as well as the
vulnerabilities for error that are rooted in human nature biases. This trigger video provides an
appropriate context for resident trainees, medical students, or any clinicians, to discuss
examples of decision making strategies and errors in action.
Objectives:
1. To differentiate the concept of cognitive error from other types of error in medical
decision making and behavior
2. To define specific underpinnings of cognitive error and identify them in one’s own
practice
3. To identify strategies for prevention of and earlier recovery from cognitive error
How and When to Use
We are now using this as a trigger video for interactive discussion in resident simulation training
courses at the University of North Carolina at Chapel Hill and at Stanford University School of
Medicine. We do not present it as a comprehensive catalogue or discussion, but rather as an
appetizer portion of behavior science applied to medical decision making. Participants are
encouraged to discuss how specific principles apply in their own practices, as well as to identify
other decision making errors that have occurred. The act of exploration and naming of
cognitive phenomena helps to create broad-reaching principles of decision making that can be
applied to a variety of clinical situations. As well, naming of these phenomena normalizes the
human experience of making an error in diagnosis, treatment, and judgment.
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Marjorie Stiegler, M.D. and Sara Goldhaber-Fiebert, M.D.
Incorporating the video into a simulation debriefing session is best done with dedicated time to
explore the concepts, roughly 30 minutes. The video is also appropriate as a trigger for
discussion in larger audiences, such as at Morbidity and Mortality Conference, or other teaching
session. One faculty facilitator is sufficient, provided they are familiar with the video and its
principles, expanded in the references listed here. A supplemental powerpoint slide deck is
included to highlight core principles, such as the myriad of influencers on decision behavior and
thus, cognitive error, as well as the concept of error blindness. The powerpoint is best as an
adjunct to the video, and best introduced after viewing the video. Additionally, a PDF exploring
the topic of “Illness Scripts” is included, which describes the cognitive consolidation of analytical
processes with experience. Illness Scripts represent Type I thinking (as discussed in the video),
and may be prone to error in the context of availability bias and memory errors.
We have found that encouraging participants to discuss prior mistakes they have made
themselves or heard about others making during emergencies or critical cases is good way to
start the session. They will often provide details of the obstacles which they felt contributed to
inadequate delivery of high-quality patient care. These details in turn set the stage for
discussing concepts of cognitive error in contrast to knowledge gaps or lack of vigilance.
Here we include specific contexts and uses of these materials, including questions for effective
discussion:
Ideas for contexts in which video (in whole or in part) may be useful as a trigger for further
discussions:
 Simulation course for any learner audience, with one of the explicit learning objectives being
awareness of cognitive errors and tools for protecting patients from the effects of clinician
cognitive errors
 Case Conference or Problem Based Learning session in which an explicit learning objective
is to understand how heuristics may lead to error when diagnoses are selected prematurely
based on “classic” pattern matching
 Morbidity & Mortality cases that contain potential cognitive errors
Potential learner audiences are vast and include:
 Pre-clinical medical students
 Residents and fellows
 Mixed-level rounding teams (including clinical medical students, residents, and fellows led by
attending or senior trainee)
 CME conferences
 Courses for board-certified physicians or other fully trained clinicians
 Inter-professional teams discussing/practicing teamwork and communication
Suggested questions facilitator may ask after learners view the video to spur discussion:
 Has anyone ever had a case where the “obvious” diagnosis turned out to be incorrect?
 Has anyone ever been involved in a case in which the diagnosis was delayed because it
was deemed too unlikely (ie, “common things are common”)?
 Has anyone ever been involved in a case in which a team member expressed a preference
for a plan because they “had been burned” by another choice in the past? These kinds of
emotional memories do not change the statistical likelihood of recurrence.
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Marjorie Stiegler, M.D. and Sara Goldhaber-Fiebert, M.D.


Has anyone ever been involved in a case in which some element of a handoff or transition of
care was erroneous, and yet became “sticky”, continuing to propagate in the chart and in the
medical decisions?
How often do you question your own “rightness” when the elements all seem to fit together
in an expected way? Is there utility in practicing that kind of self-contrarianism?
Note: we always teach that emergency manuals and cognitive aids do not replace constant
clinical judgment and broad situational awareness, and include caveat that it is one of many
tools to improve team delivery of care to patient. A key feature is to always reassess if patient
not improving as expected. Cognitive error counterbalancing strategies are particularly
important in this context.
Effectiveness and Significance
Trainees have given positive feedback about the content of this video, and clinicians of many
different specialties and professions have given similarly positive feedback in the context of
national workshops and other presentations of the content. One surgeon, with a forty year
career, reported that he felt the process of understanding a mistake he had made years ago
and carried with him as a burden for decades was cathartic and normalizing. The same is true
for trainees.
Limitations
1. The video should not be presented as a comprehensive treatment of cognitive error or
prevention strategy. Rather, in combination with references listed below, learners should
explore the broad concepts, and reflect upon their own experiences (personal and
vicarious) to identify the impact of these cognitive phenomena.
2. While the video can be effectively used for teaching within any medical discipline e.g.
Internal Medicine, Intensive Care Unit, Emergency Department, etc. and
interprofessional colleagues, e.g. nurses within single disciplines or interdisciplinary
teams) the intraoperative setting would be most familiar to Anesthesia and Surgery
trainees or clinicians.
Acknowledgments: We thank Stanford University’s Vice Provost for Online Learning as well as
each of our departments for their support, Stanford Medicine Educational Technology for video
editing, and Kevin Ang for graphic Illustrations. We also greatly appreciate the ideas and input
of our predecessors, colleagues, and students who helped to refine the ideas presented here.
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Marjorie Stiegler, M.D. and Sara Goldhaber-Fiebert, M.D.
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