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Contextual Errors in Medical Decision Making: Overlooked and Understudied

Weiner, Saul J. MD; Schwartz, Alan PhD

doi: 10.1097/ACM.0000000000001017

Although it is widely recognized that effective clinical practice requires attending to the circumstances and needs of individual patients—their life context—rather than just treating disease, the implications of not doing so are rarely assessed. What are, for instance, the consequences of prescribing a medication that is appropriate for treating a clinical condition but inappropriate for a particular individual either because she or he cannot afford it, lacks the skills to administer it correctly, or is unable to adhere to the regimen because of competing responsibilities such as working the night shift? Conversely, what are the gains to health and health care when such contextual factors are addressed? Finally, can performance measures be employed and developed for the clinician behaviors associated with contextualizing care to guide improvements in care? The authors have explored these questions through observational and experimental studies to define the parameters of patient context, introduce strategies for measuring clinician attention to patient context, and assess the impact of that attention on care planning, patient health care outcomes, and costs. The authors suggest that inattention to patient context is an underrecognized cause of medical error (“contextual error”), that detecting its presence usually requires listening in on the visit, and that it has significant implications for quality of care. Also described is preliminary work to reduce contextual errors. Evidence suggests that this nascent area of research has significant implications for performance assessment and medical education in addressing deficits in quality of care.

S.J. Weiner is staff physician and deputy director, Veterans Affairs (VA) Center of Innovation for Complex Chronic Healthcare, Jesse Brown VA Medical Centre, and professor of medicine, pediatrics, and medical education, University of Illinois at Chicago College of Medicine, Chicago, Illinois.

A. Schwartz is professor and associate head, Department of Medical Education, and research professor, Department of Pediatrics, University of Illinois at Chicago College of Medicine, Chicago, Illinois.

Funding/Support: The research described in this article was supported by the Veterans Affairs (VA), Health Services Research & Development (R&D), and the National Board of Medical Examiners.

Other disclosures: The authors are coprincipals of the Institute for Practice and Provider Performance Improvement, a firm founded to assist practices with performance improvement, including employing methods described in this manuscript. There are no other relationships or activities that could appear to have influenced the submitted work.

Ethical approval: All research described in this article was approved by the institutional review boards of the University of Illinois at Chicago and the R&D Committees of the VA facilities that participated.

Disclaimers: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs or the United States government.

Correspondence should be addressed to Saul J. Weiner, University of Illinois at Chicago, 601 S. Morgan St., 2732 UH, Chicago, IL 60607; telephone: (312) 413-2799; e-mail:

© 2016 by the Association of American Medical Colleges