Can Psychology Offer a New Approach to QI?


Sound clinical reasoning is the foundation of patient safety, yet discussions of a physician’s raw thinking ability have become a “third rail” in hospitals, according to “Incorporating Metacognition into Morbidity and Mortality Rounds: The Next Frontier in Quality Improvement,” published in the Journal of Hospital Medicine. Authors David Katz, MD, MSc, and Allan S. Detsky, MD, PhD, suggest introducing concepts from cognitive psychology could help address this issue.

The underlying problem is that the search for causes of medical error focuses on systems-based issues—medication administration and dosing, communication, physician handover, etc. There’s a reluctance to talk about human decision making. In fact, in the authors’ own hospitals, improving diagnostic accuracy is almost never discussed; they suspect the same is true at other institutions.

But cognitive errors occur predictably and often, especially at times of high cognitive load (i.e., when many complex decisions are being made in a short period of time), according to research from cognitive psychology. The authors therefore suggest that introducing metacognition (or “thinking about thinking”) discussions during morbidity and mortality rounds (MMRs) might help expand the discussions so that human error can be recognized and addressed.

They suggest that cognitive heuristics be introduced to MMRs by experienced and respected clinicians who can tell stories of their own errors and the shortcuts in thinking that may have caused them.

“Thereafter, the traditional MMR format can be used: presenting a case, describing how an experienced clinician might manage the case, and then asking the audience members for comment,” they write. “Incorporating discussions of cognitive missteps, in medical and nonmedical contexts, would help normalize the understanding that even the most experienced and smartest people fall prey to them. The tone must be positive.”


1. Katz D, Detsky AS. Incorporating metacognition into morbidity and mortality rounds: the next frontier in quality improvement. J Hosp Med. 2016;11(2):120-122. doi:10.1002/jhm.2505.

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