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 |