Volume 25, Issue 2
Lee C. Woodson, MD, Ph.D
Anesthesia Safety Editor
There has been much written lately about the impact of cognitive error on patient safety. Dr. Marjorie Stiegler has written reviews and published original research regarding cognitive error as it relates to anesthesia (ASA 2012 Refresher Course Lecture #405). She points out that cognitive errors occur in spite of adequate knowledge and skills. When we are presented with ambiguous information, especially with time constraints and stressful situations, we rely on pattern recognition, personal biases, and mental short cuts. These thought processes allow us to reach decisions quickly, efficiently, and usually with good accuracy. Cognitive psychologists refer to these mental shortcuts or “rules of thumb” as heuristics. Unfortunately, when we focus too heavily on heuristics and our biases these same thought processes can make us more prone to error.
After a literature search of cognitive errors Dr. Stiegler and her colleagues created a catalogue of cognitive errors they perceived to be most problematic to anesthesia. Debriefing sessions and a sophisticated system of analysis were used to determine the prevalence of these errors during simulated anesthesia emergencies. The three most common cognitive errors were premature closure, confirmation bias, and sunk costs. As an example, premature closure occurs when the first plausible diagnosis is accepted before full verification is made.
A list of all the cognitive errors they studied is beyond the scope of this editorial. Few strategies to reduce cognitive errors are available but awareness of the problem is the first and essential step. I encourage you to read Dr. Stiegler’s description of these errors that can degrade all our decisions. Perioperative urgency and complexity foster cognitive error. Currently a very popular intervention to reduce cognitive error is the use of checklists.
Checklists can be mental checklists such as mnemonic devices or formal checklists associated with evidence based protocols. Recently Arriaga and colleagues found a reduction in failure to follow approved critical steps in managing simulated surgical crises when OR teams had access to critical-event checklists.
Dr. Moitra from Columbia University and colleagues from 3 other university hospitals have devised evidence based modifications of ACLS protocols for the perioperative environment. Checklists reduce reliance on memory and can provide a more comprehensive differential diagnosis. But there is also concern that checklists can produce a false sense of completeness or may lead to rigid acceptance of an algorithm without recognizing individual patient variation.
Cognitive errors pose a threat to patient safety. An essential step in reducing cognitive errors is to gain an awareness of the kinds of cognitive error that are relevant to anesthesia. Although pattern recognition and personal biases may be helpful in stressful and time constrained situations, through introspection and self-critique we may be able to recognize when these mental aids are failing. The use of mental and formal checklists provides cognitive aids that may help organize our thoughts and reduce our dependence on memory.
