NursEM - Nursing in Emergency
NursEM - Nursing in Emergency
Episode 40 - Cognitive Bias
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Hello. Hello. This is landon and Monique and we are. We're actually at the park. We're at a baseball diamond, classical American for all of our American friends because we don't really play a lot of baseball here in Canada to Dewey thought the Toronto Blue Jays are pretty good, aren't they? I think they are. I wouldn't know. Yeah, I think I know a little bit more of the Toronto Blue Jays is a baseball team. Why will that much? There you go. And what? We are at a small little park in Vancouver enjoying the sunshine. Exactly. Finally Sunshine. And we're going to do a podcast in the park. Yes, we are key in Pea pod cast in park. Oh Wow, that's true. Okay. So we're going to talk a little bit about cognitive bias today. Are you saying I'm biased? Uh, we all are. I think. Oh, what did, we didn't really introduce ourselves, but I don't know if people who are used to listening to us, but maybe we should introduce ourselves. Landon and you are. I'm an emergency nurse and a critical care transport nurse and my name is monique and I am a emergency nurse practitioner and a large urban hospital in British Columbia. Perfect. Okay, so today we want to talk about how we make clinical decisions or perhaps what leads to poor or misguided decisions, which leads us to talk about cognitive bias. So what is cognitive bias and why are we talking about him? Well, these are flaws or distortions in judgment and decision making, and the reason we're talking about it today is that cognitive biases are increasingly recognized as contributors to patient safety events. I think we need to start by discussing how we as nurses determine who was sick and who is well, and often nurses will call or say that they have a gut instinct. That's how they can tell. Well, in the Merck manual, which is one of the oldest medical reference books, the section on decision making in medicine states that it is an intuitive understanding of probabilities combined with cognitive processes called heuristics to guide clinical judgment. Now, heuristics are referred to as rules of thumb, educated guesses or mental shortcuts. That usually involves pattern recognition due to prior experience. For me, this is a better way to explain a gut instinct. It is a decision we make based on our pattern recognition, our clinical experience, and are educated guests about what was probably wrong with the patient. I actually hate the term gut instinct, but I think it's because I know I think it's because we don't know how to explain it and I like this definition. I'm surprised you didn't mention anything about Merck manual being the oldest manual and and you know anything about me. Well that was your first husband, wasn't it? Oh see I had a feeling that was coming up because it was written in 18 something. Oh yes. Thank you for that. So that all sounds pretty good. But this bias can definitely to errors. And
Speaker 2the thing we have to acknowledge is that we are all biased. I'm not, of course, but, but definitely the rest of you are, as we critically look at errors in decision making, studies have looked at whether there is some commonalities that shaped these biases and once you accept that these biases exist, we can maybe attempt to guard ourselves against them. You have to acknowledge that they're there before you can try and address them. And if you say, well, I'm never biased, well the reality is you are, and until you acknowledge it, you can't. And we also have to prevent them. So that's the thing I understand and these aren't good things. So if you want to do the bass, just admit it. We're all biased and now we can move on. Unfortunately, cause cognitive bias is inconsistently reported and so it's difficult to quantify. There is, according to some literature, diagnostic errors are associated with six to 17 percent of adverse events in hospitals and 28 percent of those areas have been attributed to cognitive bias. So it's a significant problem. And I know as we described these, every single one of you is gonna resonate with one or two of them and go, Oh yeah, I've been there. Okay. Certainly more comprehensive studies are needed to determine the prevalence of cognitive biases and their potential to impact on clinical decisions, medical errors and patient outcomes. There have been more than a hundred cognitive biases identified and these are not specific biases. These are types of cognitive bias. We're going to concentrate on some of the common ones, but definitely it's something to look into and. And if you think, wow, this is something interesting, then read more about it. That's what we try to do with all our podcast.
Speaker 1I think we actually chose ones that resonated with you and I probably probably ones we may have been guilty of that maybe.
Speaker 2And the first one's called availability bias, which I definitely am never available
Speaker 1for anything. So availability bias is where recent experience with a particular diagnosis increases the chance that the same diagnosis will be made. Again, the opposite is also true so that a diagnosis that hasn't been seen in a long time is less likely to be made. In general, this will lead to rare diseases being underdiagnosed and common diseases being overdiagnosis, so for example, in the middle of the flu season, it's incredibly easy to diagnose. Every patient with shortness of breath is having the flu and then potentially missing a subtle pulmonary Embolus, a recent case buyer, so significant case bias or subtitles of this availability bias if you missed a pee and a young woman who had a vague chest discomfort, but really no other risk factors, you may want every young woman to have a d dimer plus or minus a ct scan of the chest.
Speaker 2I know that my. The common one also is the back pain.
Speaker 1Oh yeah, sorry. An aortic aneurism. Suddenly everyone has an Aortic aneurism that way. Exactly. So however experience can also lead to underestimation. Right? So one of our newer triage nurses at tree are several patients with sinkable episodes to a less acute area and they all turned out to be benign, like a Vasovagal. So the next couple of patient did not get as thorough a history taking and likely a decreased index of suspicion. And the presentation was a young man whose girlfriend said that her boyfriend was sitting on the couch and then became unconscious. She did CPR and he woke up. Wow. His father died at the age of 35 of sudden death syndrome. This is not syncope or a Vasovagal episode. I'm sorry. Anyone who's had CPR. Yeah, I don't think it's. And I don't overcomplicate tree. Oh, someone pushed on your chest. Great. Just go to the trauma room, gets. We'll, we'll have you in a side structure in five minutes. Right? So a sudden death in a young person can be caused by heart disease, including cardiomyopathy, congenital heart disease, myocarditis, genetic conductive tissue disorders, mitral valve prolapse or conduction disease medications or other courses. It also could be bragadocious syndrome, short qt syndrome, wpw. So this case is way more complicated. You don't want that at trio. So just get some them somewhere else and let them figure it out. But based on her prior experience at triage and not a lot of clinical. Exactly. So this must be not that thing exactly
Speaker 2right. Let's talk about another one which is called representation error, and this happens when someone has textbooks, textbooks, symptoms of a disease, but it is rare in that population group or there's a tendency to judge the likelihood of a diagnosis based on a typical prototype of the diagnosis. So this results in either looking for an improbable diagnosis or missing the atypical presentations of diseases. So, uh, an example, uh, a 24 year old guy who was a scene in an emergency department who had been sunbathing naked and fell asleep when he woke up. He was very sunburned and came to the Ed for some pain relief. No, let's all put in our judgment bias here. Yes, you're weird exactly. But you showed up anyway, a job security. His prints presenting complaint was chest pain. I'll be secondary to the burn. Exactly. Um, despite the fact that it would be very rare in this age group based on his history, that this would be cardiac in nature, but the nurse there chose to do a preexisting order set for cardiac chest pain, 12 lead blood work. And there we go, probably not, I don't think so. Cardiac chest pain, you'll. Yeah. So, so the best example of representation or is a chest pain thing and what we call typical chest pain. So that's the retrosternal chest pain crushing sensation into the jaw. The left arm, those studies were done on 50 year old white men. And so if you're not a 50 year old white guy in the 19 fifties, you may not necessarily present the same way. I would not think so. And so it's important
Speaker 1that we understand that. And you know, I've had a long running line that I use as, oh, you're 60 or female and diabetic with toe pain while it's probably an MRI, we should get a 12 lease and I'm often right. So. So it is acknowledging that females diabetic. So all of these other populations present differently with chest pain. So you may attribute the classical chest pain to have the wrong patient making an attribution error. So premature closure is probably one of the more common error. Most common. This is where you make a quick diagnosis often based on some pattern recognition and you failed to consider other possible diagnoses and stop collecting data. You kind of jumped to conclusion, which none of us do. I already jumped to a conclusion the summer I had a patient when I was an NP student and he had come into the hospital with a migraine. He had actually seen his GP, his GP. I've got my. I've got a headache. I'm like my typical Migraine, but the GP just heard Migraine gave him a shot of demerol who does that anymore? That is not standard of practice. I don't even know if they make demerol. I don't think we carry at any time if you're a newer nurse and don't know what [inaudible] is. It's an opioid and exactly the parody that you should not use any exactly. But uh, he got a shot of demerol, went home and then continued to have a headache and projectile vomiting and came into the emergency department. I could have easily just fallen into that migraine pattern. But being an NP student, definitely much more vigilant. And I did a whole exam. Had lateral gaze neglect, we did a CT angio and he ended up having a posterior communicating aneurysm, so there is that danger if we had, if I just prematurely just said, well, it's just a migraine and obviously [inaudible] not the right drug, I need to give him better drugs. There is a tendency in these types of errors to stop too early in your diagnostic process and not gather enough information, looking at other possible alternatives and it's kind of an umbrella category that can encompass a lot of other areas. Essentially any cognitive era could result in the belief that we have already arrived at the correct diagnosis and we don't need to go any further. The idea is when the diagnosis is made, the thinking stops. This kind of fits into this anchoring error that we talk about a lot where you hang onto a diagnosis. Even if the test prove that you're wrong, you're like, well, surely it's still this. The tests must be wrong. I am totally right. Absolutely. So there was a patient that came in for the third time. He had a history of Migraines as a child, hadn't had one for years and years to prior emerge. Doc saw the patient said that was a diagnosis, so I saw the diagnosis, saw the charts, walked in. Guy Has a headache, decide he's got a Migraine, thought, well maybe it's just an intractable migraine. I'll treat him. He felt marginally better and I thought, well, I'm going to send him home. I will send them to the neurologist feeling very proud of myself, but you know, as an outpatient he can go nothing urgent but told him come back. Sure enough, he came back worse, confused. A fourth emerge doc saw the patient and did a lumbar puncture and when you know what he had meningococcal meningitis, which I've never heard of a migraine turn into meningococcal meningitis doesn't, does it? No. Thank you for highlighting my error. So you missed something because all of us anchored into a diagnosis and that's kind of dangerous. So another interview
Speaker 2perspective on this is when a physician or NP wants to go in and see the patient without reading the nurse's assessment first, and I worked with some colleagues who get really bent out of shape about this and now that I'm in a role where I do show up and transport people, I, I can appreciate this where I see the value, the opinion that you have in there, but they want to form their own because it's really powerful if they go in blind. Yup. Ask some questions and think this is a whatever. Right. Then come out, read your notes where you've put, I think this is a whatever. It's like a bonus. We're on the same page and then they read the triage nurses notes and go, well look, all three of us were thinking the same thing versus reading your notes before they go in with that anchor of, well this is pneumonia or chf or whatever you've kind of. And maybe you don't write a diagnosis on your nurse's notes. Come on. You write enough to direct that diagnosis. Absolutely. And there you are. You know, with an anchor diagnosis that may be wrong, so yeah, it's, it's interesting and I've come to appreciate a lot more in my career that it's not a disrespect that they don't want to know anything about the patient before they go in from you. It's actually a sign of respect. Absolutely. Because they trust your judgment and they don't want to be biased by it because they will believe it. If they didn't give any credit to your judgment, they'd be like, well, I'll read whatever you want. I think it's all a bunch of crap anyway. Yeah, exactly what they're saying. They're saying, I don't want to read it because I will. I will listen to what you've written. I will approach the patient with that Lens and we know that that causes her. There's.
Speaker 1Yeah, it actually is. It actually mimics research, doesn't it? Because it validates, right? Like when you do research, you want another study, another study to validate your findings, but you can't go in there saying, I want this validated. You go in there, open minded, and then if the results validate it, you're like, oh, okay, well then maybe that's the right thing. So it's the same kind of thing. It's a fail safe, isn't it? Yeah. Yeah. Alright, we're a little bit biased obviously talking about it a little bit biased on bias. Exactly. Oh my gosh. My brain's going to explode. So next one, attribution error. So none of us have ever done this. No. You and I definitely not because I've never done perfect nurses. Absolutely. So this involves giving negative stereotypes
Speaker 2that lead us to ignore or minimize the possibilities of something worse. No, I've never, ever been. When the same person we see every day or every few days comes in smelling of alcohol again, I have never attributed a bias to that. They are just drunk. No, never. Okay. I have me too. However, those people can become hypoglycemic. Those people can be having Mris and those people could have actually fallen this time and have an intracranial injury. Exactly. Um, another good example is an intravenous drug user with back pain getting labeled as drug seeking because either maybe they have been in the past or a, that's just what the biases today at the moment, um, and they have back pain while actually it was an epidural abscess and now they're paraplegic and it just never ends well. So, you know, we're not saying be completely perfect and Oh, this would never happen, but we are saying, I acknowledge that you are making the bias so we all know we still will, you know, so-and-sos back, he's drunk again, but we're not going to assume he's just drunk. We're going to do everything. But you know, the reality is nursing station chat happens. Exactly. And just be careful. Yeah, I think you just need to have some objective measure instead of just having a subjective opinion. Yep.
Speaker 1Bias. When your thinking is shaped by prior expectations. So in other words, you see what you expect to see. This is an umbrella category that contains stereotyping and gender bias. For example, a homeless patient with a past drug abuse is found unconscious and it is assumed that he has overdosed when in fact he has severe hypoglycemia,
Speaker 2kind of very much related to the attribute. Yeah, absolutely. This is the typical patient who is drunk and we don't think they have a subdural. Uh, there was a young girl who presented with abdominal pain. I'll give you an example that's a little bit slightly different and once you lay in bed, she didn't look like she had a lot of pain.
Speaker 1Even light palpation, she cried quietly with pain when I asked the, uh, well, the nurse who actually saw the patient initially and the physician came in to see her, they felt that she was just anxious and that's why she was crying rather than thinking that she actually had a serious diagnosis. She eventually had an ultrasound which showed had ruptured appendicitis. The thing about this is that both, interestingly enough, when we talk about gender buyers, is that both of the physician and the nurse were male. And it was interesting that they saw this female crying looking when she's lying down with no pain, that it was anxiety as opposed to actually looking at something else. So that kind of ascertain and base says you expect, well maybe she's just anxious kind of thing that we look at and it's kind of interesting to me what we see as in pain or not pain, right?
Speaker 2Gender bias being one of the other biases. Yeah, exactly. We're going to talk about. But there you go. There's one of the other members. Yeah, I'm all right. Next one. Triage queuing. Or as we like to say, geography is destiny. So this is when diagnostic decisions are influenced by the original triage category that a patient is placed in. So the triage nurse diagnosed the patient is not sick, therefore the patient must not be sick. Went to the minor treatment area and you are now not sick in the minor treatment area. I'm one of that I love is when the, uh, mountain biker who flew over the handlebars going 30 kilometers and hour comes in by ambulance. It's a direct to trauma bay called the trauma team, blah, blah blah. Uh, and if you were to walk in with a shoulder dislocation, the story would get a much less acuity rating and he'd probably go to the minor treatment area. Yeah. It's a very interesting one. You come in by ambulance, you're already up triaged. It is quite interesting at first, but you're typically, you know, come in with abdominal pain on an ambulance stretcher. You may not go to the minor treatment area like you did if you walked in.
Speaker 1Exactly. And it's interesting because that whole a triage, I don't know if we are quite aware of how much power we have in those decisions up at triage and how that actually impacts the patient down the road. Yeah. Yeah.
Speaker 2So Ying Yang bias is another one, is the belief that a patient cannot possibly have a diagnosis because they already have been subjected to a multitude of negative tests. So they've been worked up
Speaker 1the Yin Yang. I liked that one, that probably the Asian part of me that likes the gang gang probably. So
Speaker 2a 35 year old came in with a swollen red arm, no trauma and lots of pain neurologically intact. No medical history, had bloodwork and an ultrasound from a different facility which was negative. So was diagnosed with cellulitis because it obviously cannot be anything, a dvt because it's already had an ultrasound and everything I'm diagnosed with cellulitis put on the outpatient antibiotic program, just was not getting any better. Antibiotics were switched. Come back, still not getting better, lots of pain. Finally, someone does another ultrasound. Guess what? He had a dvt.
Speaker 1Maybe it was an evolving one might have been small. Maybe it developed because of this, but the fact that you had a negative test once doesn't necessarily mean you have a negative test forever. So yeah, it's interesting, isn't it? It's fun. The other thing that quite a patient that's fun to acknowledge these things because I think we all sit there and go, oh yeah, I've been there. Well, I think that if things aren't going well, then we need to start at the beginning again and say, well, is there something we missed? And instead of saying, well, it can't possibly be that because we've done everything, so how could it possibly be something else? The last one that we want to talk about is framing bias. And it's where your decisions are affected by how you frame the question. I love this one. Right? So for example, when you're a very busy at triage and all the monitored beds are full and the patient comes in complaining of chest pain, you ask the patient, well, it isn't radiating down your arm, right? It isn't radiating into your jaw, right? It's not going in through to your black so that if they say no, you're justified in sending them to someplace else. Oh, you love that one. That's like, oh my gosh, yes or no question. The leading question that we're never supposed to ask in healthcare. You're suddenly, while I'm busy, I just want to know three questions and yeah. So that is one that we have to really think about. And it is difficult to sometimes allow the patient to use their own words and really listened to them and then kind of twig in and it gets busy. So we appreciate that, but again, being aware, and I always like seeing the patient dies at the same rate, whether you make it look good on the charter, not exactly know that when you're trying to justify that they are not a cardiac chest being or not septic or not, whatever. Yeah. If they are the fact that you have labeled them as not doesn't mean they start get better so you will have the cardiac arrest in the waiting room that nobody wants and exactly don't. Don't take the burden of the system upon you as a, as a triage nurse, specifically arc test to chest pain, make them a Tsi test to chest pain and let someone else deal with absolutely need to go. You will be far more criticized down, triaging a cardiac problem, then you will not having a bed to put them in. Absolutely, and I think the other thing for us perhaps we've talked a lot about errors and biases and certainly people would say, well, if you're going to look for errors, you're going to find them, but isn't that what nursing or medicine is all about? It's about quality improvement. It's about responsibility, it's about accountability for looking for the errors inside the body, what we are trained to look for errors, and I think you've said this a number of times, London, we have to first acknowledge that we are better at bias and we are vulnerable to making errors due to many factors that some of them within our control and sometimes not, and these include the stresses of patient flow, surge as a patient, volume, expectations of the patient, that you figure it out, long shifts being understaffed, all of this, but this should not mean that we get a get out of jail free card. In fact, it is in those circumstances that you actually need to be a little bit more vigilant. I'll have to tell you that I'm probably slower at the end of my shifts with intaking patients as an NP because I recognize that I'm probably less vigilant. That's why surgeons want to do, you know, you want your operation done in the morning as opposed to the last case. That fatigue, sadly. So we to look at how do we mitigate some of these risks for ourselves and I talk about all the problems we have. How do we get that therapy? Yeah. Well it was, you know, I've told you one way of I that I do it to mitigate some of my risks. The joint commission in the US in October 2016 discussed a bunch of strategies to mitigate cognitive bias or you don't know what the joint commission is. It's kind of their accrediting body. Yes. For Healthcare Organization organized a way more powerful way than our accreditation body and it's very much tied to funding whether your hospital can be open, whether you get federal funding. So when the joint commission says stuff in theU , s, and I know all of our American people are right now doing the proverbial eye-roll yeah. It needs it. It gets acted on. Absolutely. Whether it makes sense or not, it gets out. Scot got credibility behind it. So in 2016 it came up with a bunch of strategies and one of them is enhanced knowledge and awareness of cognitive bias. So how we do it, certainly in a lot of other hospitals is m, m, m rounds, maybe a reflective case review, maybe a case that we put out there and say, Hey, what do you guys think? This is what happened, providing sim training, which we're very big on, and that allows you to have muscle memory because you're going to see this over and over again. So it helps. Secondly to enhance professional reasoning and critical thinking and decision making skills. So maybe even having a diagnostic timeout now that you know when you're doing, say a pea arrest, this is a great one because you can actually get people to do because it's kind of wrote right at pea arrest, allows you to keep on doing cpr, give Epinephrin, and then you know, the decision maker takes a time out, steps back and go, okay, keep on doing that while I try to figure out what's going on here. Opponents of pasta on the running of the arrest to the nurse, we know how to do it exactly. Cpr to minute rhythm tracks. If you're related, if needed to give some epinephrin yep, carry on. Yeah, I'm actually gonna go look at this person's blood work. Exactly, and not get a history really visually present exactly what I can make better decisions to not have that. The influence of the visual. The other thing is when we're giving information like using a professional way of reporting like an s bar or something like that, that gives objective measures. Again, allowing us to have that professional decision making. Again, Sim training and definitely immediate feedback so that we can kind of figure out what's going on. So if I used to when I would be triaging patients and if I would treat them to a less acute area and then all of a sudden I see that they've been moved somewhere else. I think it's really important for you to go back and say, what did I miss? Because that's how we learn. So be proactive and looking and saying, oh my gosh. Or be the other person on the other side to the goes up and has a discussion with somebody. For example, I had a very interesting case of somebody who got with hydrofluoric acid and that's a very dangerous burn. You get it with denture, like with a denture lab or in glass etching, and it leaks out your calcium and attaches to the calcium in your body, which is you get a rhythmia's and everything like that, and they had made a c task for and sent it down to our minor treatment area. And that is a cts to you needs to be monitored. They need, uh, to be put with some calcium gluconate jail right away. And so I went right up to them and I said, by the way, this doesn't happen. You very rarely see hydrofluoric acid burns. So this is something you should know about. So I think that's important for us as professionals to take some accountability when we see it happen to ourselves and for us to give our professional feedback as necessary.
Speaker 2We always have a joke where, where we work that you never want to be a triage in here. Trauma team nurses to treat minor treatment room, whatever. Everyone looks at each other and you're looking at the beadboard and refreshing it every five seconds to see which patient moves to the trauma bay. And you're like, oh good, it wasn't exactly in and if it is one of yours, that promotion of going and going, what did I miss something? Sometimes you you did, but it just got sicker and it's good reflective. Right? So it's very good. Reflective practice. All right, so third thing from the joint commission, enhanced work system conditions and workflow design that affect cognition. So promote conditions that facilitate perception, recognition and good decision making. So useful into information displays, adequate lighting, a supportive layout, try to limit distractions, interruptions and noise. This is a big one and I know as, as someone who's providing a little more independent care now in, in my critical care job is I, I'm so easily distracted by people coming in, interrupting me in the middle of something. And I, I think back to my many years of of emergency nursing, how many times I popped in while on emerge doc seeing a patient and gone, can I just ask you something about that guy over there? And thinking back now, I was like, you know what, there's probably zero times that I actually need to do that. Versus wait a couple minutes, even actually if they went into cardiac arrest. Yeah, we're fine without you for a couple of minutes. Starting everything up, you know it's. But that distraction is so important to throwing people off their game and I know I'm very susceptible to that now. So now the thing limit cognitive loading, fatigue, maybe shorter shifts and in high cognitive areas like triage. I'm not moving patients around the emergency department so much way. Right? Because I now have to learn another patient, another patient, another patient. You put all the sick patients in the same assignment. That's difficult for the patient and the physician who may be assigned to that or the nurse and the physician who is assigned to those areas. We had a recent tour of a large department in Canada here where each little pod had their own resuscitation room and so they would actually spread out the medical resuscitation, so it's so neat. It's in this pot of 15 beds. There's three or four of you working and you each have your monitored beds. You're non monitored beds and your little resuscitation room and you will operate as a little mini emergency departments inside a larger one and so and they ran their resuscitations independently in that pod. So how great that you're not overburdening one area with everything exactly. Facilitate real time decision making, reduced the alliance reliance on memory, so technology, clinical decision support system, cognitive aids, algorithms. We are not expected to know everything. We use calculators, use a flow charts, clinical decision pathways. It doesn't mean you're less of a clinician because you pull out a flow chart at three in the morning and go, have we done everything here? Make a friend promote inter and interprofessional collaboration and teamwork to verify assumptions. Really, if, if, if the healthcare team that you work on is not at the point now it's 2018 people, everyone needs to get rid of hierarchy and all sit around and go, okay, this is what I'm thinking. Anyone else have any ideas? And you know, I would get out of an organization myself if, if I was still expected to get up and give someone my chair because of professional stature or that kind of thing, it just, it does not promote the best care, not at all for thing from, from the joint commission, promote an organizational culture that supports decision making processes. So this is, you know, almost repetitive at this point, but a supportive, safe, non punitive reporting culture. That's a big thing. If you report something, there is no punishment for that. It's not, oh you brought it up and I'm not gonna put you at triage to bring up patient care issues that trash none of that. You can't have that culture or people will slip through the cracks. Actively include consideration of cognitive bias in patient safety incident analysis. So when you're looking for root causes, bias should be one of those things you're looking for as to why something went wrong. Engage and empower patients and families to partner in their care and you know, be asking questions like we should be allowing patients totally not allowing. But I hate the word encouraging them because it's their body and I always, every time I leave a room, before I leave I say, do you have any other questions? Do you have any questions about what I've said? And I find that that partnership. Yeah. And I, I often in my job will then have to go consult with a physician before we get on the road and I, I warn the family go, so I'm just going to go speak to a physician. We're probably going to be leaving in the next five to 10 minutes. Do you have any questions before we leave? When I come back I'll ask you again. So it gives them kind of five to 10 minutes to think of some and let's be honest to google what I've said exactly. Look at some questions and, and present them again because in my world they're going to be then getting in a car and driving to the next city where I'm taking them and I don't want them to be stewing. Oh, I just
Speaker 1thought of this question. So, so I find that, you know, do you have any questions now? And you know what, I'm going to come back in five minutes and the department one time thing and a department that seats 400 people a day that may not be practical. I'm in a different bit of a world there, but yeah. But yeah, I don't think it's acknowledged that they may not think of all the questions right then. Yeah. Alright. So our final word is one, we make mistakes except us to. We must understand why we make those mistakes. Three, we must learn from them and for we need to mitigate risk by improving our cognitive and physical environment. Excellent. Thank you very much. I wondering if you can hear all the birds in the tree. It's quite lovely. It's, we're helping our safe. A safe environment for Landon and I hearing the birds is very relaxing. Maybe we should be playing that in emergency waiting rooms podcast in the park every, every time. And she even made muffins, muffins in the park. Amazing. This doesn't get better. No, not today. Unfortunately in our country. Wine Park
Speaker 3doesn't fly. It's just going to be muffins. Well, we'll see you next month. Next month. Bye. Past episodes and to comment on this episode, please visit our website at [inaudible] dot org. You can follow us on twitter at nursing past and also find us on facebook at [inaudible] podcast. We look forward to your comments and suggestions for future episodes. Remember before incorporating anything new into your work, ensure you were supported by your own scope of practice, workplace policies, and your own knowledge and comfort. The podcast is brought to you by prn education, www dot prn education dot. Yeah, ca.
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