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MEdIC Case: The Case of the Cognitive Overload


Welcome to season 4, episode 1 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

In this month’s case, a junior resident deals with some of the harsh realities of emergency medicine when she experiences the negative impacts of cognitive overload when caring for a sick patient.

MEdIC Series: The Concept

MEdIC: The Case of Cognitive Overload

By Dr. Sarah Luckett-Gatopoulos

Haley had come to think of the nurses in the emergency department as lifesavers. As a first year resident, she often found the nurses’ clinical acumen far exceeded her own; they sometimes reminded her to order investigations she hadn’t yet thought to initiate, and occasionally began the diagnostic workup with bloodwork while she was waiting to review with her staff preceptor. She started to think of the nursing staff as one of her safety nets in the department.

The department this evening was unusually busy and as a result of recent nursing shortages several nurses were working double shifts. When a nurse from the triage desk came into the department and asked Haley to see a tachypneic young man being wheeled into the resuscitation bay, naturally, she immediately put down the chart she was working on and went to assess the patient.

The 20-year-old man with a known history of asthma was tachypneic and appeared diaphoretic. The paramedics reported that he had been febrile and coughing for the past week, to the point that his ribs ached with each breath. He had tried using his rescue inhalers, but their effect was diminishing as the illness progressed. Over the past 24 hours his breathing had worsened and his cough was now productive of green sputum. Upon auscultating his lungs, Haley could hear extensive crackles in the right lung field with associated diffuse wheezing. Now highly concerned for pneumonia, she glanced up at the cardiorespiratory monitor which revealed that his heart rate was elevated at 135 and respiratory rate was 30. She figured that given the severity of his symptoms and presentation she should promptly initiate the departmental “sepsis protocol” while she waited to review the case with her attending, Dr. George.

‘Hi, I don’t think we’ve met. I’m Haley, one of the first year emergency medicine residents. I will be filling out the sepsis order set for this young asthmatic here in resuscitation bay 5. He looks pretty sick and I’m quite concerned about him. Could you start some of the work-up right away and I’ll review this with Dr. George as soon as he’s available.’ Haley signed the sepsis protocol, which included an order for extensive blood work, blood cultures and a litre of normal saline to be administered. She thought it would be most appropriate to review the case with Dr. George before proceeding with additional orders.

‘Not to worry,’ the nurse replied. ‘I’ve already started these,’ she gestured to the blood work order set in her hand. ‘I’ve put in 2 IVs, sent off blood work and cultures and he has some fluids running. I’ve also called the respiratory therapist to come assess him.”

Relieved that she had a veteran nurse on the case, Haley quickly reviewed the case with Dr. George. Following her discussion with her attending Haley signed a new order sheet, which included additional IV fluids, antibiotics, chest x-ray, urinalysis, and nebulizer treatments. She quickly dropped the new order sheet on the patient’s chart and then picked up a new patient’s chart. The next case was a simple finger fracture so she figured she’d have time to care for this patient while managing the sick asthmatic.

Upon completing the care for the patient with the finger injury, Haley was called into a trauma case and assisted with a chest tube. She then went back to review the board and realized she hadn’t checked on the asthmatic patient in almost 2 hours. She logged into the image viewing system to review his chest x-ray and was surprised to find it hadn’t been completed.

She approached the patient’s nurse and asked, ‘Do you know why our patient in resuscitation bay 5 hasn’t had his x-ray?’

‘Oh… I didn’t put that in. That’s your job.’ she replied. The nurse was simultaneously balancing the care for 5 emergency patients and appeared slightly flustered.

Haley glanced over at the patient who now appeared increasingly uncomfortable and fatigued. The respiratory therapist had started some nebulizer treatments but the patient appeared to be clinically deteriorating. Haley nervously asked the nurse, ‘How much fluid has he received? Did you give him anything for pain? Did you start the antibiotics?’

The nurse looked up at Haley, ‘I sent off blood work and started a bolus of saline as we discussed earlier. We can’t start additional interventions without a doctor’s orders. You need to order it if you want it done.’

Haley flipped through the order set in the patient’s chart and sure enough, her signed order sheet was right where she had placed it earlier. Haley had been so confident the orders would be completed. This nurse was one of the best she had worked with and she didn’t think she would have to get after her to do the work. Haley could feel her cheeks getting red… She kept thinking, ‘how could I have let this patient sit here for 2 hours without additional fluids or antibiotics! If he continues to deteriorate, this is on me!”

Discussion Questions

  1. How could Haley have avoided this dilemma?
  2. What strategies can physicians employ to lighten the cognitive load, decrease stress and avoid medical error?
  3. Should Haley disclose this medical error with the patient and how should she go about it?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

This month’s experts

  • Dr. Amy Walsh
  • Dr. Jimmie Leppink

On October 14, 2016 we will post the curated commentary and expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba
  • Shawn Mondoux

    1. How could Haley have avoided this dilemma?
    – Good opportunity for activities surrounding metacognition: What were Haley’s assumptions about care? Why might this have happened? Why did this error occur?
    – This case is a good example of Reason swiss cheese model ( whereby an error is due to a series of opportunities to identify the potential error, but it was never prevented. Previous shift “non-errors” were essentially caught by “one slice of swiss cheese”.
    – A solution, at any level, whether conscious or not, could have eliminated the error
    – Maybe we shouldn’t count on humans to avoid error. Maybe we should design the system to “catch” and prevent human error, rather than depending on the human to modify behaviour and appreciate risk at every layer.
    – It is Haley’s role to reflect and modify behaviour but it is the system’s responsibility to stop this from happening, despite her behaviour.
    2. What strategies can physicians employ to lighten the cognitive load, decrease stress and avoid medical error?
    – Closed loop communication
    – Deferral of procedures when simultaneous critically ill patients – focus on CRM skills
    – Set pocket timers for reassessment on electronic device
    – See resource issues in the ED, discuss with the charge nurse and request help in the room with critical patients
    – Perform a root cause analysis of the error, identify opportunities for improvement and modify the system
    3. Should Haley disclose this medical error with the patient and how should she go about it?
    – Yes, without question. It should be done when the patient is less critically ill. Apologize for delay in treatment, explain the risk. Do this with family at the bedside and inform them of steps to change the process.
    – Should be captured in the hospital safety learning system as a near miss/harm event
    – Should force system change to prevent similar issues

    • John Eicken


      Thanks so much for your thoughtful insights on Haley’s situation. I agree this case is an excellent example of the swiss cheese model you refer to and agree that appropriate utilization of technology can assist in avoiding future recurrence of similar errors. In your opinion, what would an ideal “system” or “technology” look like? I have worked in ED’s where patient’s names are “flagged” on the EMR board (i.e. sepsis or psychiatric emergency) to aid providers in avoiding errors and meet treatment timing goals. While this approach seems to have a positive impact on patient care I wonder if there are other approaches (both currently in practice or theoretical) that could further optimize the “system” in helping to prevent error.

      • Shawn Mondoux

        If the forum will indulge this, I’d like to use an analogy. System errors (such as in this case) are the clinical equivalent to chief complaints. They are an expression of the problem at hand, but definitely aren’t its full definition. We would never dream of treating every “chest pain” patient with blood thinners (assuming PE) although in some cases, it would be appropriate. We always take the time to do a good history, physical exam and diagnostic tests to better understand the distribution of bayesian probabilities (despite the fact that we may have some cognitive hangups and use some elements of system 1 thinking).

        Jumping to a fix here would be no different. We could choose to treat the problem in a variety of ways and, in some instances, any one might be effective. But it behooves us to follow the error through its many loopholes (history), look at the situations in the ED at the time of the error (Physical Exam) and create a set of diagnostic tools (review previous near misses or errors, ask why they were caught, identify safety elements in the system, appreciate the major flaw). This way we can target an intervention that we know has much larger bayesian probability of fixing the problem.

        Something as simple as having a flag system on a clipboard chart identifying incomplete orders could work in this case. More complex fixes might include Hayley ID’ing in the EMR that this is a case of sepsis and it would start a visible ticking clock (say limit to 15 mins) by which Abx must be given.

        The essential bit is doing the diagnostic work. Not easy. And not universally applicable (as each hospital has their own really). But well worth the time.

    • Loice Swisher

      On disclosure- I’m not convinced that it should be Haley that discloses this. I would see this being Dr George’s responsibility. This is tricky as Haley wrote the orders which were not carried out. If she does do the disclosing, how does she answer typical patient questions like “what went wrong”, “could it happen to someone else”, “what can you do so it doesn’t happen again”.

      Haley seems defensive- and then it can be easily to say “I wrote the order but the nurse didn’t take it off.”

      I would hope that there is training in Just Culture to fix the system rather than punish the individual.

  • Loice Swisher

    I come from an American system in which our residents rotate between hospitals every 3 1/2 weeks or so. The hospital systems use different EMRs and are set up differently. In addition, forward rotating schedule deals with the shift work issues but causes residents to be interacting with different teams- day/night, weekday/weekend. Thus, it seems impossible for residents-particularly early on to gel as a team.

    I believe that Dr. George bears significantly more responsibility for the delay. We as teaching attendings need to not only focus on content but also process. Communication issues are a known problem- particularly when there are overworked/understaffed problems. We need to teach the pearls and tips of great communication.

    My guess is that many of us are reminded of this lesson on a regular basis- labs that are delayed going off because the nurse “didn’t see the labels” or a CT delayed because of no pregnancy test. It is an imperfect system and the trick is to try to have a system where the fewest things fall through the cracks- and to be significantly aware on those patients who may be sick.

    We have multiple ways of potentially communicating with nurses with our EMRs- mail, comments, orders and possibly zone phones if they are using them. I’m working on asking nurses which is their preferred communication. It works for me but I only work nights in a community ED which limits the number of nurses I come in contact with.

    The take-home point for Haley is that she needs to figure out ways to check on sick patients. In addition, she needs to develop her protective style when working with a new person.

    • These are really important points @Loice! What are advice/tips that you have for new attendings who are supervising even more junior residents? Do your attendings get teaching/orientation on how to safely supervise?

      • Loice Swisher

        No there is no orientation. Generally none of our new attendings are put on single coverage time until they have been at our hospital for a month. There is an assumption that you will have learned this- how to supervise and prevent errors just by going through a residency. It isn’t the same- especially since 24 hour attending coverage (which I totally understand but I don’t think that residents quite ever feel that “the buck stops here” in residency.

        The learning is the same as for Haley- trial and error- sink or swim.

        Is this different in Canada?

        Honestly I am not cynical but here are my 5 rules to live by to keep me safe:
        Everybody lies.
        Nobody tells the truth.
        Don’t trust anybody else ever.
        If you want it done right, do it yourself.
        Always maintain a high index of suspicion.

        Obviously this is exaggeration or hyperbole. However if it is an important point I always check it myself. And I don’t think that it is always that people mean to be deceitful but they just have a different understanding. For example, in my place patients don’t consider beer alcohol- alcohol is hard liquor- you have to ask specifically beer or wine as well. Also insulin isn’t a medicine because it isn’t a pill. And yes we have had the ‘no I’m not sexually active I just lie there.”

        And one has to realize that when the system is overstretched this is the time that you have employ cognitive strategies to be even more careful as that is the more error-prone situation.

  • Kaif Pardhan

    1&2. How could Haley have avoided this dilemma/What strategies can physicians employ to lighten the cognitive load, decrease stress and avoid medical error?

    I could definitely see this happening to anyone in the ED – whether it be an experienced staff physician or a junior resident. On the day that is described in the case it looks like everyone is having a rough time – it’s busy department with an over-extended nursing staff. I agree with Shawn that the Swiss cheese model is certainly applicable here and that there are probably several factors that would have helped to prevent this.

    From a very practical standpoint, it may be helpful to stay at the bedside until all of the critical interventions have been carried out – or at least started (I still do this). Haley, as a PGY-1, isn’t responsible for flowing the department – and it’s a good experience to see how long different interventions take to carry out: How long does it take to mix up Pip-Tazo or give a ventolin neb? It’s also sometimes nice to have a second/third pair of hands to help put on monitors, spike the IV bag, pump up the pressure bag, etc.

    It’s also helpful, when you’re ready to leave and see the next patient, to double check what is pending with the nurses – their cognitive load is often as high (if not higher) than ours. We also, often, don’t have a way to flag new orders in the resus bay (at least not in the places where I’ve worked) – so it’s even more important that everyone in the room is on the same page regarding which direction the care will be going.

    3. Should Haley disclose this medical error with the patient and how should she go about it?
    Agree with the comments so far – this responsibility should certainly not be Haley’s alone and, as she is a PGY-1, Dr. George should play a significant role – either coaching her through the disclosure, or modelling disclosure techniques. The disclosure should occur at a time when the patient is not as critically ill. That said, if the patient deteriorates and needs to be intubated, a case could certainly be made that disclosure should be made to the family (if they are present) once the patient is stable – and the patient can be informed at a later point in time.

    Incidents like this should always be viewed as an opportunity for quality improvement and the department and hospital are, as Shawn points out, responsible for the system changes to avoid this type of issue.

    • Loice Swisher

      I absolutely agree that Haley should not be or feel responsible for patient flow. I find that there seems to be increasing competition on pt per hour that we are not encouraging education.

      I feel that Haley should not have left the room either. She should see the trajectory of disease with different interventions. This is a potentially critical patient and deserves critical care time. I was less worried about hitting the marks for a sepsis protocol versus an asthmatic who goes bad potentially needing intubation. This is one would want her to stay until the Xray was done and probably the VBG- or having an endtidal CO2 set up.

      In this case the error Haley made was moving on to another patient before stabilizing and establishing a safety net for a sick patient. This is one to call for a portable chest x-ray stat. Leaving the patient gives other the feeling that you think that the patient is OK.

      There is quite a bit of learning to be done from this case but probably can be best done later with some serious reflection with more time.

    • Tamara McColl

      Such a great point @kaifpardhan:disqus ! I agree that, in general, much focus has been put on the flow and management of an emergency department that we sometimes compromise the learning opportunities/education of our residents, as well as put undue stress on them to see more patients which can ultimately have a negative impact on patient care as we see in this case.

      You also bring up the crux of this case in communication breakdown – other than directly speaking to this nurse about additional orders, what other checks and balances could be implemented to prevent this case from happening again? Our department has an EMR which highlights the nurses name when new orders are put in and there’s also this great “MD to Nurse Communication” note on the white board where attendings/residents can communicate orders, concerns, patient updates etc to the treating RN. Do you have any other helpful tools at your centre?