Henriksen K, Kaplan H
Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, MD 20850, USA.
Qual Saf Health Care. 2003 Dec;12 Suppl 2(Suppl 2):ii46-50. doi: 10.1136/qhc.12.suppl_2.ii46.
The ubiquitous nature of hindsight bias is a cause for concern for those engaged in investigations and retrospective analysis of medical error. Hindsight does not equal foresight. Investigations that are anchored to outcome knowledge run the risk of not capturing the complexities and uncertainties facing sharp end personnel and why their actions made sense at the time. Important lessons go unlearned if the exercise is simply to back track someone else's decision landmarks. Outcome knowledge can also bias our thinking on the quality of the processes that led to the outcome. This paper examines the influence of outcome knowledge in relation to reconstructive memory and legal testimony, ways for reducing the impact of outcome knowledge, and an adaptive learning framework that places hindsight bias in a broader context of rapid updating of knowledge.
后见之明偏差的普遍存在，让那些从事医疗差错调查和回顾性分析的人深感担忧。后见之明并不等同于先见之明。基于结果知识进行的调查，有可能无法捕捉一线人员所面临的复杂性和不确定性，以及他们当时的行为为何合理。如果只是简单地追溯他人的决策节点，重要的经验教训就会被忽视。结果知识还可能使我们对导致该结果的过程质量的思考产生偏差。本文探讨了结果知识在重构记忆和法律证词方面的影响、减少结果知识影响的方法，以及一个将后见之明偏差置于知识快速更新的更广泛背景下的适应性学习框架。
