Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association
RESEARCH ARTICLE

Decision-making under pressure: medical errors in uncertain and dynamic environments

Alicia M. Zavala A B F , Gary E. Day A , David Plummer C and Anita Bamford-Wade B C
+ Author Affiliations
- Author Affiliations

A School of Medicine, Griffith University, Gold Coast Campus, 58 Parklands Drive, Southport, Qld 4215, Australia. Email: g.day@griffith.edu.au

B Ministry of Public Health, Republica del Salvador Avenue 36-64 and Suecia Postal code 170515, Quito, Ecuador.

C College of Public Health, Medical & Veterinary Sciences, James Cook University, Townsville, Qld 4811, Australia. Email: david.plummer@jcu.edu.au

D Menzies Health Research Institute Queensland, G40 Griffith Health Centre, Level 8.86, Gold Coast Campus, Griffith University, Qld 4222, Australia. Email: anita.bamford-wade@health.qld.au

E The Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Qld 4215, Australia. Email: anita.bamford-wade@health.qld.au

F Corresponding author. Email: alicia.zavalacalahorrano@griffithuni.edu.au

Australian Health Review - https://doi.org/10.1071/AH16088
Submitted: 22 April 2016  Accepted: 3 April 2017   Published online: 5 June 2017

Abstract

Objective This paper provides a narrative overview of the literature concerning clinical decision-making processes when staff come under pressure, particularly in uncertain, dynamic and emergency situations.

Methods Studies between 1980 and 2015 were analysed using a six-phase thematic analysis framework to achieve an in-depth understanding of the complex origins of medical errors that occur when people and systems are under pressure and how work pressure affects clinical performance and patient outcomes. Literature searches were conducted using a Summons Search Service platform; search criteria included a variety of methodologies, resulting in the identification of 95 papers relevant to the present review.

Results Six themes emerged in the present narrative review using thematic analysis: organisational systems, workload, time pressure, teamwork, individual human factors and case complexity. This analysis highlights that clinical outcomes in emergency situations are the result of a variety of interconnecting factors. These factors may affect the ability of clinical staff in emergency situations to provide quality, safe care in a timely manner.

Conclusions The challenge for researchers is to build the body of knowledge concerning the safe management of patients, particularly where clinicians are working under pressure. This understanding is important for developing pathways that optimise clinical decision making in uncertain and dynamic environments.

What is known about the topic? Emergency departments (EDs) are characterised by high complexity, high throughput and greater uncertainty compared with routine hospital wards or out-patient situations, and the ED is therefore prone to unpredictable workflows and non-replicable conditions when presented with unique and complex cases.

What does this paper add? Clinical decision making can be affected by pressures with complex origins, including organisational systems, workload, time constraints, teamwork, human factors and case complexity. Interactions between these factors at different levels of the decision-making process can increase the complexity of problems and the resulting decisions to be made.

What are the implications for practitioners? The findings of the present study provide further evidence that consideration of medical errors should be seen primarily from a ‘whole-of-system’ perspective rather than as being primarily the responsibility of individuals. Although there are strategies in place in healthcare organisations to eliminate errors, they still occur. In order to achieve a better understanding of medical errors in clinical practice in times of uncertainty, it is necessary to identify how diverse pressures can affect clinical decisions, and how these interact to influence clinical outcomes.

Additional keywords: emergency departments, patient safety.


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