By Duane Penshorn, MD

In 1999, researcher Dr. Kathleen Mosier placed 25 experienced pilots in a high-tech flight simulator. Her goal was to measure their response to inaccurate automated alerts. When cockpit instruments indicated an engine fire, the protocol was to verify the condition with other sensors. Instead, every one of the 25 pilots shut down the affected engine, responding to the false positive warning, an error of commission. In another scenario, the simulated plane’s altitude was too low, but the low altitude indicator did not signal an alert. More than half of the pilots failed to recognize the false negative signal and did not correct the plane’s altitude. This failure to recognize the faulty indicator in a life-threatening situation was an error of omission.

When Dr. Mosier analyzed the data, she noticed that the pilots with more experience were more likely to believe the computerized alerts because they had worked side by side for years with the system, and they trusted its accuracy. The junior pilots still possessed healthy skepticism and had not conditioned themselves through experience with the flawless automation. The experienced pilots blindly followed the screen’s directive despite evidence to the contrary and considered the automated warnings to be an infallible authority. Dr. Mosier coined the term “automation bias.” This is the tendency to believe automated cues as a shortcut to vigilant information-seeking.

In the emergency room, we operate in a high-stress environment with multiple inputs, similar to an airline pilot. There are multiple interfaces with the laboratory, radiology, and EKGs, all connected via the electronic medical record systems. We are trained to treat the information we receive as the absolute truth, not as a piece of data that needs to be analyzed.

A few months ago, I came into the emergency department and took over a few turnovers from the offgoing shift. One of the patients I received a report on was getting ready to receive aggressive replenishment of electrolytes due to critically low calcium and potassium. When I asked the other clinician why these values were low, they said they didn’t have a good reason. When we reviewed the chemistry panel, we saw a pattern: all of the chemistry values were half of what they should be, except sodium and chloride. The sample had been drawn from an IV port without collecting waste and had been contaminated with sodium chloride. This was an inevitable result of the pressure for throughput metrics.

My colleague had fallen into a digital trap. They had grown accustomed to the lab values being accurate, and despite not having any clinical signs or reason for these abnormalities, they had been prompted to order immediate corrective action. A prompt, framed as a “best practice advisory” for patient safety, effectively became cognitive blinders. If the team had carried out these orders, the patient may have suffered a lethal arrhythmia and had an unfortunate outcome.

In a high-stress environment, when the brain is under a constant barrage of information, it looks for shortcuts to help offload the work. The EHR flags these results and prompts an easy click to order the replacement, the path of least resistance. It was designed to streamline throughput and optimize billing compliance, not to improve clinical accuracy. When we deal with a flood of noncritical pop-ups and hard stops that need to be addressed before you can place orders, it becomes impossible to function without taking every shortcut we can find.

We need to take the radiologist’s advice and make sure everything clinically correlates. When the lab, X-ray, or EKG does not match the patient’s clinical presentation, the study might just be wrong, so you need to look out the window and fly the plane.

Duane Penshorn is an investigative nonfiction author and thriller writer. A practicing emergency physician, former ER medical director, and hospital chief of staff, he draws on decades of frontline clinical and forensic training to diagnose the hidden corporate frameworks shaping modern life. He writes about what happens when institutional design clashes with real-world patient care, exposing the metrics and bureaucratic bottlenecks that drive clinician burnout and threaten safety.

Penshorn brings the same clinical realism to his fiction as an award-finalist science fiction and medical thriller author. As the founder of Astus Press, he writes across genres to explore the unintended consequences of complex modern systems, advocating for a return to intuition over dashboard compliance. He practices at Baptist Neighborhood Hospital and lives in San Antonio, Texas.