Context Is Everything or How Could I Have Been That Stupid?

Dual Process Theory provides a useful working model of decision-making. It broadly divides decision-making into intuitive (System 1) and analytical (System 2) processes. System 1 is especially dependent on contextual cues. There appears to be a universal human tendency to contextualize information, mostly in an effort to imbue meaning but also, perhaps, to conserve cognitive energy. Most decision errors occur in System 1, and this has two major implications. The first is that insufficient account may have been taken out of context when the original decision was made. Secondly, in trying to learn from decision failures, we need the highest fidelity of context reconstruction as possible. It should be appreciated that learning from past events is inevitably an imperfect process. Retrospective investigations, such as root-cause analysis, critical incident review, morbidity and mortality rounds and legal investigations, all suffer the limitation that they cannot faithfully reconstruct the context in which decisions were made and from which actions followed.