Acute coronary syndrome (ACS), including acute myocardial infarction and unstable angina, is one of the most common physician-reported missed diagnoses. The majority of ACS patients present to the health care system via emergency departments (EDs), where the rate of missed acute myocardial infarction is up to 4 percent and of missed unstable angina more than 2 percent. The vast majority of diagnostic errors can be attributed to cognitive errors, stemming from the complexity of the health care system. When working memory is overloaded, physicians are distracted and information processing becomes less efficient, such that information is lost from working memory and performance suffers, threatening patient safety. Mental workload is determined by a combination of task demands, environmental contextual factors, and the skill, experience, and attention of the physician. Thus, workflows, facilities, and environments built to improve “cognitive hygiene”–defined as a state of clinical workflow that optimizes physicians’ cognitive capacities to engage in expert diagnostic decision-making –should lead to less mental overload. Such an ideal system in the ED would ultimately increase patient safety.
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