What did you just do?

Protocols are in place to help clinicians make fewer mistakes, but medical errors continue to rise. Sara Williams asks whether better awareness of a new phenomenon called involuntary automaticity would make patients safer.

Every day doctors are held responsible for errors in the delivery of care. But what if some of these mishaps were beyond their control?

Last year Brian Toft, Professor of Risk Management at Coventry University, published a paper proposing a newly identified social-psychological phenomenon called involuntary automaticity (IA) to explain one of the root causes of human error.

Both the Scottish and English Chief Medical Officers called for the paper and it was raised in the House of Commons and at the European Union patient safety summit in 2005. However, there is an urgent need to carry out research to find out how prevalent IA is in modern medicine.

In the paper Toft identified a cognitive mechanism that causes people to miss cues that are right before their eyes despite double-checking protocols in place to pick up on them. He argues that the main problem is not making errors, but missing them.

Automaticity is acquired by repeating the same activity. For example, when you learn to drive you have to concentrate, but once the ritual has been learned, you pay more attention to other drivers and rowdy passengers than to the action itself; you sail along on auto-pilot. Toft argues that this becomes IA when those actions have become ritualised and the brain’s cognitive checking mechanism takes on a life of its own.
In hospitals with patient safety inspired protocols, those procedures may be inducing error rather than preventing it.

“Instead of paying attention to what you are actually doing, the rules of the action take over and they govern your perception of your actions,” explains Toft. “This can be hazardous in clinical settings, as staff could say that an action has been taken, even when it has not.”