This article has been peer reviewed and accepted for publication. It is in production and has not been edited, so may differ from the final published form.
Decision-making under pressure: medical errors in uncertain and dynamic environments.
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, 95 research papers were analysed using Braun and Clark’s (2006) 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. Results. Six themes emerged in this narrative review, namely: organisational systems, workload, time pressure, teamwork, individual human factors, and case complexity. This highlights that clinical outcomes in emergency situations are the result of a variety of interconnecting factors that may affect the ability of clinical staff to provide healthcare. Conclusions. The challenge for researchers is to build the body of knowledge concerning the safe management of patients and developing pathways that optimise clinical decision-making, particularly where clinicians are working under pressure. What is known about the topic? Emergency departments are characterised by high complexity, high throughput and greater uncertainty compared to routine hospital wards or outpatient situations, therefore the ED is prone to unpredictable workflows in non-replicable conditions complex cases. What does this paper add? Clinical decision-making process can be affected by pressures with complex origins, including the six topics described. Interactions between these factors can increase the complexity of clinical problems. What are the implications for practitioners? These findings provide further evidence that consideration of medical errors should be seen primarily from a ‘whole-of-systems’ perspective rather than as being primarily the responsibility of individuals. 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 medical decisions, and how these interact to influence clinical outcomes.
AH16088 Accepted 03 April 2017
© CSIRO 2017