Patient safety and the anaesthetist
Keywords:biases, cognitive errors, crew resource management, dual process thinking, heuristics, metacognition, normalisation of deviance, system 1, system 2
All physicians have an ethical duty towards their patients to protect them from harm (nonmaleficence) and to do what is in their best interest (beneficence). This, in essence, relates to patient safety. Many patients have the expectation that the health profession should function without ever making a mistake. In reality, medical professionals are also humans and humans make mistakes.
A safer healthcare system depends on awareness about the vulnerability of the entire system. Critical incident analysis provides an opportunity to identify areas of concern and to institute corrective measures even in cases where a critical incident did not result in harm.1,2 Anaesthetists should be trained in understanding cognitive processes related to decision making, as well as the potential errors that can occur in the system and in themselves. They should recognise the possible contributors to cognitive errors and develop ways to mitigate those risks. Institutions should have policies in place to avoid system errors that can lead to individual errors and subsequent patient harm. It is everyone’s responsibility to ensure proper team management, leadership, assertiveness, communication, collaboration, professionalism, and self-reflection.3,4
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