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Safety Tip of the Month

Brought to you by the ASA Patient Safety Editorial Board

Biased About Our Biases:

How Cognitive Bias Impacts Patient Safety

H
uman thinking is based on ac- Knowing that cognitive bias is common 2. Avoiding associated negativity of the
quired, processed, and stored and often leads to patient safety concerns terms to reduce feelings of weakness,
knowledge. Personal beliefs, should lead us to find mitigation techniques. poor judgment, or lack of objectivity.
emotions, and experiences are Croskerry advocates for raising awareness 3. Making cognitive processing less in-
also stored and incorporated into thought of biases, using decision-making aids and visible by practicing metacognition,
processes. Bias is defined as a preference algorithms, and fostering a culture of open- reflective practice, and cognitive bias
toward or away from an idea or action. It mindedness and self-­reflection within clini- awareness and challenging your own bi-

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is a personal reality based on perception of cal practice (Diagnosis 2014;1:23-7). Royce ases, becoming a more critical thinker.
available information that includes knowl- suggests considering open communication 4. Acknowledging that some unknowns
edge and emotional inputs. Cognitive bias opportunities such as diagnostic time outs for are unknown.
is an error in thinking that influences how challenging cases, and Singh suggests avoid- 5. Considering application of Bayesian
we make decisions. It can result in a closed- ing the view that diagnostic errors are per- reasoning and artificial intelligence.
minded or prejudicial approach and may be sonal failings and suggests changing the term We must acknowledge the contri-
learned or innate. Biases may lead to dis- “diagnostic error” to “missed opportunities butions of bias to our medical decision-­
torted perceptions or inaccurate judgment. in diagnosis” (Acad Med 2019;94:187-94; Jt making. We wish to believe that we have
Both cognitive and implicit biases are innate but we all perform our day-to-day clinical Comm J Qual Patient Saf 2014;40:99-101). the right answers, yet our colleagues might
to human thinking and cannot be elimi- decision-making reliant on pattern recogni- Steps to mitigate errors due to cognitive offer alternate choices. Embrace the op-
nated. Consequently, bias is an inevitable tion and heuristics, and biases are incorpo- bias could include (Cogn Res Princ Implic portunity to use metacognition techniques
and sometimes unwelcome contributor to rated into our thinking. Heuristics are fast, 2023;8:13): to think critically, be open to a­ lternate
diagnostic reasoning (Diagnosis 2014;1:23-7). intuitive, efficient, and low-stress mental 1. Raising awareness by defining and dis- analyses, and be reflective in your practice
It has become well established that cog- techniques that suit the high-paced, stressful cussing the terms heuristics and bias. of medical decision-making. 
nitive biases are a significant problem in environments like ORs. The dual-process
medical decision-making. Flaws in judg- theory model of decision-making describes
ment, rather than lack of knowledge, are two mental processes in learning and Cognitive Biases and Definitions
central to diagnostic error (BMJ Qual Saf ­decision-making. Heuristics are type 1 think-
2013;22:ii58-ii64; Otolaryngol Clin North ing processes that are adaptive and allow for ANCHORING OVERCONFIDENCE BIAS
Focusing on one issue at the Inappropriate boldness, not
Am 2019;52:35-46). Arnot describes biases rapid decision-making. Type 2 processes, expense of understanding the recognizing the need for help
as predictable deviations from rationality, known as metacognition, are analytical, whole situation
and lack of ongoing improvement in qual- slower, deliberate, and conscious processes.
ity and safety initiatives may be due to the Type 1 decision-making is most used and usu- AVAILABILITY BIAS OMISSION BIAS
failure to focus on the importance of diag- ally effective, but more prone to error than Choosing a diagnosis because it is Hesitation to start emergency
nostic errors and the role of cognitive bias type 2 decision-­making. Our daily actions in the forefront of your mind due to procedures – fear of being wrong
a bad memory of a bad experience or causing harm
in these errors (Information systems journal are conducted based on serial associations,
2006;16:55-78; N Engl J Med 2013;368:2445- which tend to trigger the next, side-step-
8; Healthc Q 2012;15:50-6). The magnitude ping analytical thinking and incorporating PREMATURE CLOSURE SUNK COSTS
Accepting a diagnosis prematurely, Unwillingness to let go of a failing
of the problem is alarmingly high. The diag- errors in a domino effect. Type 2 processes failure to consider reasonable diagnosis or decision
nostic error rate is estimated to be 10%-15% are slow and require cognitive resources but differential of possibilities
(Otolaryngol Clin North Am 2019;52:35-46). are safe and dependable. However, there can
A study of closed claims cases found that be flaws in type 2 thinking when analytically FEEDBACK BIAS VISCERAL BIAS
64% of the outcomes were due to diagnostic applied strategies are based on flawed rules Misinterpretation of no feedback Negative or positive feelings about
error, and most of those were thought to be (Science 1974;185:1124-31; BMJ Qual Saf as ‘positive’ feedback a patient influencing our decisions
due to a failure of judgment (Ann Intern Med 2013;22:ii58-ii64).
2006;145:488-96). Other studies of diagnos- Stiegler et al published a pilot study of CONFIRMATION BIAS ZEBRA RETREAT
tic delay and misdiagnosis also show a high cognitive errors in anesthesiology. Out of Seeking or acknowledging only Rare diagnosis likely but hesitant
rate of diagnostic error due to cognitive bias the hundreds of possible cognitive biases, information that confirms the to pursue it because it is rare
desired or suspected diagnosis
(Acad Med 2019;94:187-94). the authors generated a top 14 catalog
Despite varied efforts to improve patient prevalent in anesthesiology (Br J Anaesth
safety in medicine, cognitive bias is not dis- 2012;108:229-35) (Table). They subse- FRAMING EFFECT UNPACKING PRINCIPLE
Subsequent thinking is swayed Failure to elicit all relevant
cussed much. It might be uncomfortable to quently scored the cognitive errors most by leading aspects of initial information, especially during
admit that we can make diagnostic errors, observed in simulated scenarios. Premature presentation transfer of care
closure and confirmation bias were the
ASA Patient Safety Editorial Board
most observed, and framing effect and COMMISSION BIAS PSYCH-OUT ERROR
contributors: Deborah Schwengel, MD,
MEd, FASA (Editor-in-Chief); Alexander
availability bias were the least observed. Tendency toward action rather than Medical causes for behavioral
F. Arriaga, MD, MPH, ScD; Jonathan In a study of the surgical literature, inaction – deviating from protocol. problems are missed in favor of
Armstrong and colleagues found that the May be due to overconfidence, psychological diagnosis
B. Cohen, MD; Jeffrey A. Green, MD,
most common types of bias were overcon- desperation, or pressure from others
MSHA, FASA, ScD; Keith J. Ruskin, MD;
Senthilkumar Sadhasivam, MD, MPH, MBA, fidence, anchoring, and confirmation bias Table: Catalog of Top Cognitive Biases (adapted from Stiegler et al) (Br J Anaesth
FASA; Scott C. Watkins, MD. (Br J Surg 2023;110:645-54). 2012;108:229-35).