Are Cognitive Errors Well Described in the Anesthesia Literature?
Cognitive errors are inadequately described in the anesthesia literature, with only limited formal attention given to this critical safety issue despite its widespread recognition in other high-risk fields like aviation and other medical specialties. 1
Current State of Literature on Cognitive Errors in Anesthesia
The anesthesia literature has historically neglected the psychology of decision-making and cognitive error patterns, representing a significant gap compared to other safety-critical domains. 1 While cognitive errors are thought to contribute significantly to medical mishaps, formal study of these thought-process errors in anesthesiology practice has been sparse. 1
Key Cognitive Errors Identified in Anesthesia Practice
A landmark 2012 study in the British Journal of Anaesthesia identified the most important cognitive errors specific to anesthesiology through expert consensus and observational research. 1 The "top 10" cognitive errors most prevalent in anesthesia practice include:
- Anchoring - fixating on initial impressions despite contradictory evidence 1
- Availability bias - overweighting recent or memorable cases 1
- Premature closure - accepting a diagnosis before full verification 1
- Feedback bias - misinterpreting or ignoring corrective information 1
- Framing effect - being influenced by how information is presented 1
- Confirmation bias - seeking only information that supports initial hypotheses 1
- Omission bias - preferring inaction over action to avoid blame 1
- Commission bias - preferring action over inaction 1
- Overconfidence - overestimating one's abilities or knowledge 1
- Sunk costs - continuing a failing course due to prior investment 1
In simulated anesthesia emergencies, seven of nine observed cognitive error types occurred in more than 50% of cases, demonstrating their pervasive nature. 1
Contrast with Medication Errors
The anesthesia literature has extensively documented medication errors rather than cognitive errors. 2 Medication errors occur in 5.3% of drug administrations during surgery, with 79.3% deemed preventable. 2 Common medication errors include wrong dose, substitution, repetition, and omission. 2
This represents a critical imbalance: while technical and procedural errors receive substantial attention through rigorous literature reviews and expert consensus recommendations, the underlying cognitive processes that lead to these errors remain understudied. 2
Recent Recognition of the Problem
More recent literature acknowledges that cognitive errors play important roles during surgical procedures, with studies outside anesthesia (such as colorectal surgery) demonstrating cognitive errors in 7 of 8 analyzed cases of anastomotic failure. 3 Decision-making research in anesthesiology has begun addressing heuristics and mental shortcuts that allow rapid decisions but may cause diagnostic and treatment errors. 4, 5
Anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors, yet the extent to which cognitive processes contribute to anesthesia practice errors remains unknown. 5
Critical Gap in Knowledge
The fundamental problem is that while cognitive diagnostic errors are well-known in medicine broadly, cognitive heuristic errors during the course of surgical and anesthetic treatment have been downplayed, underestimated, or simply ignored. 3 This represents a dangerous blind spot in a specialty where human error poses significant risk for hospitalized patients. 2
Practical Implications
Understanding key cognitive error types specific to anesthesiology represents the first step toward training in metacognition and de-biasing strategies that may improve patient safety. 1 Simple decision-making checklists can help anesthesiologists monitor their own thought processes and make correct decisions. 4 Risk assessment tools adapted from aviation can help determine hazards associated with particular clinical management strategies. 4
The bottom line: Cognitive errors in anesthesia are poorly described in the literature relative to their clinical importance, with most attention focused on downstream consequences (medication errors, adverse events) rather than the underlying cognitive processes that generate these errors. 1, 5