Prospective memory failures as an unexplored threat to patient safety: results from a pilot study using patient simulators to investigate the missed execution of intentions

Authors: Dieckmann, P.¹; Reddersen, S.¹; Wehner, T.²; Rall, M.¹

Source: Ergonomics, Volume 49, Numbers 5-6, -6/15 April–15 May 2006 , pp. 526-543(18)

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Abstract:

This study investigated failures of prospective memory (PM) as a relevant but neglected error type in medicine. A patient simulator was used to investigate PM failures. The influence of subjective importance (high, low) and type of intention (educational, internal, external) on the (missed) execution of intention was investigated in a 2 × 2 design. The effects on missed executions by importance (high 2 tests. Interaction was significant for missed executions ( p = 0.025; n = 19; df = 2; χ 2 = 7.41) and for executions ( p = 0.002; n = 54; df = 2; χ 2 = 12.50). Despite low statistical support and some methodological limitations, it was possible to show that PM failures are relevant to patient safety and that patient simulators are a suitable but so far unused tool for their investigation.

Keywords: Prospective memory; Patient safety; Simulation; Human error

Document Type: Research article

DOI: http://dx.doi.org/10.1080/00140130600568782

Affiliations: 1: Center for Patient Safety and Simulation (TuPASS), Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tuebingen, University of Tuebingen, Medical School, Hoppe-Seyler-Str. 3, D-72076, Tuebingen, Germany 2: Center for Organizational and Occupational Sciences, Swiss Federal Institute of Technology, Kreuzplatz 5, H13, CH-8032, Zurich, Switzerland

Publication date: 2006-01-01

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