Tunnel Vision
by Marwa Hassan
Photograph by Marwa Hassan
How many times have I walked through this tunnel? Often swiftly to avoid the bitter cold, with one hand grasping my coat closed and my head facing the ground to avoid the wind. But on this day, the air was crisp, the sun ready to set, and the temperature a perfect 55. I took a moment. A moment to look left and right. I saw trees, so many of them. They had lost all their leaves. Were there leaves there before? Why hadn’t I noticed that they were gone? I had fallen victim to tunnel vision.
In medicine, we have fixation errors, also referred to as “anchoring” errors or “tunnel vision”. In medicine, these are the errors that can make you fail to see the trees. But what exactly is a fixation error? It is when a provider concentrates solely on a single aspect of a case, causing them to ignore other more important aspects. This can result in missed diagnoses, etiologies, and ultimately increased morbidity and mortality.
Human errors have been estimated to account for 87% of all medical errors. From one specialty to another, human error incidence varies. According to Chandran et al., up to 83% of medical errors in anesthesia are due to human error. Fixation errors account for a significant portion of these errors.
What can be done to combat anchoring bias that leads to fixation errors? Awareness is a key first step in reducing any type of bias, but awareness alone is insufficient. Strategies proposed incurrent literature to reduce fixation errors in anesthesia, that can likely be extended to other specialties, include the following:
Rule out the worst-case scenario
Recognize that one’s first assumption could be wrong
Assume artifacts to be the last explanation for a problem
Avoid biasing team members with prior made conclusions
Implement the use of cognitive aids such as algorithms, checklists, mnemonics, and computerized prompts to avoid fixation during acute emergencies or crises.
While these strategies can be employed individually, institutions may benefit from implementing strategies to combat anchoring bias and reduce fixation errors among trainees and providers. Awareness can be raised using articles, didactic education, and case studies highlighting the dangers of anchoring bias. Stimulated training sessions can then provide hands-on experience to practice counteracting such dangers. Formal plans and strategies must be provided to trainees to mitigate the error rate, such as fostering proper communication among team members and utilizing reporting systems to identify prior errors as a means of future error prevention.
Just as I was made aware of the trees, I hope that you are now more aware of the dangers of tunnel vision. This piece serves as a reminder to myself to do my best not to fixate on one diagnosis, one cause of change in a patient’s health, or one treatment option as I move forward in my medical career. I hope it can serve as a reminder to others, too.
References
Chandran, R., & De Sousa, K. A. (2014). Human factors in anaesthetic crisis. World Journal of Anesthesiology, 3(3), 203-212. https://doi.org/10.5313/wja.v3.i3.203
Fioratou, E., Flin, R., & Glavin, R. (2010). No simple fix for fixation errors: cognitive processes and their clinical applications. Anaesthesia, 65(1), 61–69. https://doi.org/10.1111/j.1365-2044.2009.05994.x
Ortega, R., & Nasrullah, K. (2019). On reducing fixation errors. Journal of Anesthesia Patient Safety Foundation, 25(3), 167-174.
Sameera, V., Bindra, A., & Rath, G. P. (2021). Human errors and their prevention in healthcare. Journal of anaesthesiology, clinical pharmacology, 37(3), 328–335. https://doi.org/10.4103/joacp.JOACP_364_19
Stiegler, M. P., Neelankavil, J. P., Canales, C., & Dhillon, A. (2012). Cognitive errors detected in anaesthesiology: A literature review and pilot study. British Journal of Anaesthesia. 108(2), 229-235. https://doi.org/10.1093/bja/aer387
Tewfik, G., Rivoli, S., & Harbell, M. W. (2023). Recognizing and combating cognitive bias in anesthesiology: Implications for patient safety. Journal of Anesthesia Patient Safety Foundation, 39(4), 302-310.
Walsh, T., & Beatty, P. C. W. (2002). Human factors error and patient monitoring. Physiological measurement, 23(3). https://doi.org/10.1088/0967-3334/23/3/201
Marwa Hassan is a fourth-year medical student at the UTCOMLS.
