Features  |   May 2013
Cognitive Errors and Cognitive Aids in Anesthesiology
Author Affiliations
  • Marjorie Podraza Stiegler, M.D.
    Committee on Patient Safety and Education
Article Information
Airway Management / Central and Peripheral Nervous Systems / Infectious Disease / Ophthalmologic Anesthesia / Patient Safety / Technology / Equipment / Monitoring / Trauma / Burn Care / Quality Improvement / Features
Features   |   May 2013
Cognitive Errors and Cognitive Aids in Anesthesiology
ASA Monitor 05 2013, Vol.77, 10-12.
ASA Monitor 05 2013, Vol.77, 10-12.
What does it feel like to be wrong? How can we recognize a mistake when we are making it? We are oblivious to our errors at the time that we make them, because being wrong feels exactly like being right. This is the idea of “error blindness.”1  The time that elapses between making a wrong decision and subsequently recognizing it ranges from very short (a few seconds) to very long (months to years, or never at all). As physicians, we have an obligation to prevent as many errors as possible, and to recover quickly and optimally when errors do occur. An important component of diagnostic and therapeutic decision-making mistakes is cognitive error – thought process errors made despite adequate knowledge and skill, and often in the setting of good intentions. Cognitive errors may be rooted in bias, heuristical decision-making, overconfidence, illogical thought preferences and other subconscious phenomena, leading to mistakes in anesthesiology decision-making.2  Here, we will discuss just a few examples of cognitive errors and the circumstances that might surround them. A catalog is presented in Table 1, and more comprehensive discussions are available elsewhere.3  In addition, we will discuss how cognitive aids can assist with prevention and recovery from these errors.
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