Book Text

Hazardous Attitudes

Attitudes are an important component of ability that can affect performance as strongly as physiologic performance-shaping factors.^[161] Psychologists studying judgment in aviators have identified five attitude types as being particularly hazardous, and they have developed specific antidote thoughts for each hazardous attitude.^[162] These attitudes as related to anesthesia are shown in Table 83-6 . The aviation psychologists instruct pilots physically to verbalize the antidote thought whenever they find themselves thinking in a hazardous way.

The invulnerable and macho attitudes are particularly hazardous for anesthetists. They are compounded by production pressures to handle more cases in less time with fewer cancellations and with less opportunity for

TABLE 83-5 -- Fixation error types and countermeasures

Fixation error 1: "This and only this!"

Persistent failure to revise a diagnosis or plan despite plentiful evidence to the contrary. Available evidence interpreted to fit the initial diagnosis. Attention allocated to a minor aspect of a major problem.

Countermeasure: Apply dynamic decision-making. Accept the possibility that first assumptions may be wrong. Verify data (see Table 83-3 ). Go through the model of the core process (see Table 83-2 ). Call for consultant help to verify your diagnosis. Be aware of fixation errors!

Fixation error 2: "Everything but this!"

Persistent failure to commit to the definitive treatment of a major problem.

Extended search for information made without ever addressing potentially catastrophic conditions.

Countermeasure: "Rule out worst case"; assume that the worst possible diagnosis is true and prove to yourself that this is not true. The assumption that "probable things are probable and rare things are rare" may run you into trouble. Step back—review the whole situation.

Fixation error 3: "Everything is OK!"

Persistent belief that no problem is occurring in spite of plentiful evidence that it is. Abnormalities attributed to artifacts or transients. Failure to declare an emergency or accept help when facing a major crisis. Failure to switch from "business as usual" to "emergency mode."

Countermeasures: Remind yourself that artifacts are the last explanation for changes in critical values. Stay ahead of the game and call for help rather early.

preoperative evaluation. The feeling that a catastrophe "cannot happen to me" and that perfect performance can always be called on to avert a disaster can lead to cavalier behavior and poor planning. It can alter thresholds for believing that abnormal data represent a problem, thereby leading to the fixation error of "everything's OK." In 1984, Cooper and colleagues^[163] wrote the following about their studies of critical incidents in anesthesia:

**TABLE 83-5** -- Fixation error types and countermeasures
Fixation error 1: "This and only this!"
Persistent failure to revise a diagnosis or plan despite plentiful evidence to the contrary. Available evidence interpreted to fit the initial diagnosis. Attention allocated to a minor aspect of a major problem.
Countermeasure: Apply dynamic decision-making. Accept the possibility that first assumptions may be wrong. Verify data (see Table 83-3 ). Go through the model of the core process (see Table 83-2 ). Call for consultant help to verify your diagnosis. Be aware of fixation errors!
Fixation error 2: "Everything but this!"
Persistent failure to commit to the definitive treatment of a major problem.
Extended search for information made without ever addressing potentially catastrophic conditions.
Countermeasure: "Rule out worst case"; assume that the worst possible diagnosis is true and prove to yourself that this is not true. The assumption that "probable things are probable and rare things are rare" may run you into trouble. Step back—review the whole situation.
Fixation error 3: "Everything is OK!"
Persistent belief that no problem is occurring in spite of plentiful evidence that it is. Abnormalities attributed to artifacts or transients. Failure to declare an emergency or accept help when facing a major crisis. Failure to switch from "business as usual" to "emergency mode."
Countermeasures: Remind yourself that artifacts are the last explanation for changes in critical values. Stay ahead of the game and call for help rather early.

Perhaps the most insidious hazard of anesthesia is its relative safety. The individual anesthetist rarely, on average, will be responsible for a serious iatrogenic complication. It is our impression from the process of collecting incidents, that most seemingly minor errors are not taken seriously and that risk management depends almost solely on the anesthetist's ability to react instinctively and flawlessly every time a problem arises.

Expert human performance is the anesthetist's most powerful tool to safeguard the patient. However, planning to avoid catastrophe is likely to be more successful than battling to avert it.