Connecting the Dots: The Influence of Risk Perception on Patient Safety*

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Excerpt

The concept of risk helps us to understand and cope with danger and uncertainty. The perception of risk varies across individuals, however, and may be inconsistent, even for a single individual, depending on the context. Thus a person’s perception of risk can be dependent, for example, upon the features of the physical environment, which can affect the perceived likelihood of a negative outcome, as well as upon the seriousness of such an outcome if it does occur (1, 2). There is ample experimental evidence that people also invent heuristics and may introduce biases when they assess the amount of risk in their environment (1). Perceptions influence decision-making about how to behave in potentially risky situations, and this involves the amalgamation and interpretation of multiple types of information drawn from a variety of sources. Thus, risk assessment can be a difficult cognitive process. Yet, risk perception is a critical antecedent of behaviors that introduce risk (3). A misjudgment of risk may thus lead to inappropriate decisions or human errors, which in medical settings often compromise safety. The article published in this issue of Critical Care Medicine by D’Lima et al (4) is accordingly timely in that it addresses how the perception of staffing risks in a complex environment, namely the ICU, may affect promoting and regulating safety.
Risk perception, including the way we think (cognition), feel (emotion), and behave (behavior) in response to risk, is highly relevant to considerations of patient safety. Unfortunately, there is limited research on the factors that affect such perceptions in the healthcare environment, including intensive care settings, and what has been reported is largely based on survey data rather than any in-depth analysis into the underlying cognitive processes (5, 6). D’Lima et al (4) use semistructured interviews to elicit attitudes of intensive care professionals in an effort to identify cognitive processes underlying their perceptions of ICU staffing risks. This is a step forward in elucidating perceptions of risk, and some underlying patterns of thinking by the health professionals, on suitable staffing levels for intensive care environments.
To capture the underlying cognitive processes for perception of risks, robust methodologies are required. One well-known technique for modeling problem-solving and decision-making processes is to use “think-aloud” approaches, which involve having participants describe what they are thinking as they are performing a set of specified tasks (7, 8). In medicine, these tasks can include processes such as interviewing a patient or walking through a clinical problem-solving scenario (e.g., reaching a diagnosis or devising a management or therapeutic plan) (9). This approach is particularly useful in capturing error progression and risk assessment in complex real-time environments, such as the ICU, where the clinical workflow process does not proceed in regimented steps but is nonlinear, with associated varying boundaries of risks over time (10, 11). Using think-aloud techniques during task performance, the process of making decisions under different risk conditions, which is usually implicit, is made more explicit and is available for further inspection and analysis.
A variation of this method is cognitive interviewing, the technique used by D’Lima et al (4). In their work, the subject is asked predetermined (structured) survey questions, followed by having the interviewer probe for more details (through partially open-ended questions). The responses are recorded and analyzed qualitatively, using a theoretically driven method of data coding (12), which helps the researchers to identify specific strategies that participants use to perceive, and to interpret, the questions.

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