Incidence of cognitive errors in difficult airway management: an inference human factors study from the Pediatric Difficult Intubation Registry

Martina Bordini; Luca Orsini; Simon Y W Li; Julia Olsen; Mary Lyn Stein; Lina A Sarmiento Argüello; Emily B Hesselink; Angela C Lee; Piedad C Echeverry; Lisa K Lee; Elizabeth M O'Brien; Priti G Dalal; Agnes Hunyady; Simon Whyte; Melissa Brooks-Peterson; Annery G Garcia-Marcinkiewicz; Pete Kovatsis; James Peyton; Britta S Von Ungern-Sternberg; John Fiadjoe; Clyde Matava; PeDI Collaborative Group

doi:10.1016/j.bja.2025.04.033

Incidence of cognitive errors in difficult airway management: an inference human factors study from the Pediatric Difficult Intubation Registry

Br J Anaesth. 2025 May 29:S0007-0912(25)00279-X. doi: 10.1016/j.bja.2025.04.033. Online ahead of print.

Authors

Martina Bordini¹, Luca Orsini², Simon Y W Li³, Julia Olsen⁴, Mary Lyn Stein⁵, Lina A Sarmiento Argüello⁶, Emily B Hesselink⁷, Angela C Lee⁸, Piedad C Echeverry⁹, Lisa K Lee¹⁰, Elizabeth M O'Brien¹¹, Priti G Dalal¹², Agnes Hunyady¹³, Simon Whyte¹⁴, Melissa Brooks-Peterson¹⁵, Annery G Garcia-Marcinkiewicz¹⁶, Pete Kovatsis⁵, James Peyton⁵, Britta S Von Ungern-Sternberg¹⁷, John Fiadjoe¹¹, Clyde Matava¹⁸; PeDI Collaborative Group

Affiliations

¹ Department of Anesthesia & Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; DIMEC, University of Bologna, Bologna, Italy.
² Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; DIMEC, University of Bologna, Bologna, Italy.
³ School of Psychological Science, The University of Western Australia, Perth, WA, Australia; Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, WA, Australia.
⁴ Department of Anesthesia & Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
⁵ Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA.
⁶ Department of Pediatric Anesthesiology, Instituto Nacional de Pediatría, Mexico City, Mexico; Department of Pediatric Anesthesiology, Centro Pediátrico del Corazón ABC-Kardias, Mexico City, Mexico.
⁷ Anesthesiology, University of Wisconsin-Madison, Madison, WI, USA.
⁸ Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, DC, USA; Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
⁹ Anesthesia, Instituto Roosevelt, Bogota, Colombia.
¹⁰ Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA, USA.
¹¹ Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
¹² Anesthesiology and Peri-operative Medicine, Penn State Health Children's Hospital, Hershey, PA, USA.
¹³ Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, WA, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
¹⁴ Department of Anesthesia, British Columbia's Children's Hospital, Vancouver, BC, Canada; Anesthesia, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.
¹⁵ Division of Pediatric Anesthesiology Administrative Offices, Children's Hospital Colorado, Denver, CO, USA.
¹⁶ Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, WA, USA.
¹⁷ Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Nedlands, WA, Australia; Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, WA, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, WA, Australia; Perioperative Care Program, Perioperative Medicine Team, The Kids Research Institute Australia, Nedlands, WA, Australia.
¹⁸ Department of Anesthesia & Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada. Electronic address: clyde.matava@sickkids.ca.

PMID: 40447486
DOI: 10.1016/j.bja.2025.04.033

Abstract

Background: Cognitive errors are known contributors to poor decision-making in healthcare. However, their incidence and extent of their contribution to negative outcomes during difficult airway management are unknown. We aimed to identify cognitive errors during paediatric difficult airway management using data from the Pediatric Difficult Intubation (PeDI) registry, to determine patient and clinician factors associated with these errors, and their contribution to complications.

Methods: We conducted a retrospective analysis of the PeDI registry data including cases with at least three intubation attempts. Cognitive error definitions were adapted to airway management, and predefined clinical endpoints were used to identify cognitive errors. A subanalysis was performed for children weighing <5 kg. Our primary outcome was the overall incidence of cognitive errors. Secondary outcomes included the incidence of specific cognitive error subtypes, associations with patient and clinician factors, and the relationship between cognitive errors and complications.

Results: Cognitive errors were identified in 17.4% (487/2801) of cases, with fixation errors being the most common (11.5%), followed by omission bias (5.9%) and overconfidence bias (4.5%). Non-anaesthesiologist clinicians had the highest odds of cognitive errors. The presence of at least one cognitive error was independently associated with a higher risk of complications (adjusted odds ratio, 1.86 [95% confidence interval, 1.53-2.27]; P<0.001), and multiple errors increased the likelihood of severe complications (adjusted odds ratio, 2.48 [95% confidence interval, 1.24-4.94]; P=0.01).

Conclusions: Cognitive errors occurred in nearly 20% of paediatric difficult airway encounters and were linked to increased complications. Further research should refine error definitions and develop mitigation strategies to improve outcomes.

Keywords: airway management; bias; cognitive error; difficult airway; human factors; human performance; medical error; paediatric difficult airway.