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Table 2 Cognitive Errors, Definitions and Illustrations from anesthesiology acc. to Stiegler et al.4; Illustrations from surgery as described in this study

From: Cognition errors in the treatment course of patients with anastomotic failure after colorectal resection

Cognitive Error

Definition

Illustration from anesthesiology

Illustrations from surgery

Anchoring

Focusing on one issue at the expense of understanding the whole situation

While troubleshooting an alarm on an infusion pump, you are unaware of sudden surgical bleeding and hypotension

Vascular surgeon focuses on aortic aneurism, but disregards changes indicating carcinoma in the sigma. The aneurism is eliminated first leading to a change in perfusion further adding to the changes in blood supply in the colon. The sigma is excised afterwards under ischemic conditions.

Availibility bias

Choosing a diagnosis because it is in the forefront of your mind due to an emotionally charged memory of a bad experience

Diagnosing simple bronchospasm as anaphylaxis because you once had a case of anaphylaxis that had a very poor outcome

The standard for protecting anastomosis is ileostomy. Therefore an ileostomy was performed although the colon was loaded with feces hindering proper protection of the downstream colon

Premature Closure

Accepting a diagnosis prematurely, failure to consider reasonable differential of possibilities

Assuming that hypotension in a trauma patient is due to bleeding, and missing the pneumothorax

 

Feedback Bias

Misinterpretation of no feedback as ‘positive’ feedback

Belief that you have never had a case of unintentional awareness, because you have never received a complaint about it

 

Confirmation bias

Seeking or acknowledging only information that confirms the desired or suspected diagnosis

Repeatedly cycling an arterial pressure cuff, changing cuff sizes, and locations, because you ‘do not believe’ the low

reading

 

Framing effect

Subsequent thinking is swayed by leading aspects of initial presentation

After being told by a colleague, ‘this patient was extremely anxious preoperatively’, you attribute postoperative agitation

to her personality rather than low blood sugar

 

Commission bias

Tendency toward action rather than inaction. Performing un-indicated manoeuvres, deviating from protocol. May be due to overconfidence, desperation, or pressure from others

‘Better safe than sorry’ insertion of additional unnecessary invasive monitors or access; potentially resulting in a complication

Two specialized surgeons perform a sigma-rectum-resection. The performing surgeon notices fatty residues on the dorsal part of residual rectum (Fig. 2), which the assisting but more experienced surgeon judges to be of no relevance (overconfidence). Due to the resulting pressure the less experienced surgeon, despite his own concerns, made the unindicated decision in favor of an anastomosis, leading to anastomotic leak on the dorsal (fatty) part of the anastomosis.

Overconfidence bias

Inappropriate boldness, not recognizing the need for help, tendency to believe we are infallible

Delay in calling for help when you have trouble intubating, because you are sure you will eventually succeed

The necessary standard of performing perfusion control was not met. An explanation for divergence from protocol was deemed unnecessary

Omission bias

Hesitation to start emergency manoeuvres for fear of being wrong or causing harm, tendency towards inaction

Delay in calling for chest tube placements when you suspect a pneumothorax, because you may be wrong and you will be responsible for that procedure

1. Although indicated to establish absence of tension no severance of the mesocolon out of concern that perfusion possibly might be compromised (Fig. 3)

2. After resection of rectum and bladder a small rigid bladder residue remained, complicating establishing an anastomosis. Instead of Hartmann-resection according to protocol, a primary anastomosis with upstream ileostomy was performed due to fear of worse conditions for later reattachment.

Sunk costs

Unwillingness to let go of a failing diagnosis or decision, especially if much time/resources have already been allocated. Ego may play a role

Having decided that a patient needs an awake fibreoptic intubation, refusing to consider alternative plans despite multiple unsuccessful attempts

After conforming to the standards for checking for the perfusion of the intestinal region responsible for the anastomosis, a small livid discoloration is noticed on the aboral part of the anastomosis. (Fig. 4). Due to the long-lasting surgical procedure in accordance to standards, the discoloration is judged to be of no further concern. A leak develops in this region.

Visceral bias

Counter-transference; our negative or positive feelings about a patient influencing our decisions

Not trouble-shooting an epidural for a laboring patient, because she is ‘high-maintenance’ or a ‘complainer’

 

Zebra retreat

Rare diagnosis figures prominently among possibilities, but physician is hesitant to pursue it

Try to ‘explain away’ hypercarbia when MH should be considered

 

Unpacking principle

Failure to elicit all relevant information, especially during transfer of care

Omission of key test results, medical history, or surgical event

 

Psych-out-error

Medical causes for behavioural problems are missed in favour of psychological diagnosis

Elderly patient in PACU is combative—prescribing restraints instead of considering hypoxia