Fixation bias in healthcare. How to see the light at the end of the tunnel ?

What is it about? 

The accreditation system feedback database collects care-related adverse events occurring during the routine practice of physicians and medical teams. The lessons learned are used to develop patient safety solutions (PSS) designed to improve practices, reduce the occurrence of events or mitigate their consequences. Type-3 PSSs are produced by the HAS in liaison with accreditation bodies. 

We live in a complex environment, with a vast amount of data to take on board and analyse, but we have limited cognitive capacities. We therefore use mental shortcuts on a daily basis, which help us to make quick and usually reliable decisions. These shortcuts are indispensable, but can sometimes be a source of error if used in the wrong situation, resulting in cognitive bias, which includes the fixation phenomenon.  

Here, fixation is defined as being any situation in which a healthcare professional’s attention is so highly focused on a specific goal that he or she fails to notice warning signs that should normally prompt a change in approach or even the stoppage of the procedure before an adverse event can occur. 

The aim of this PSS is to raise awareness among healthcare professionals of fixation and the cognitive mechanisms that may impair reasoning and clinical decision-making, and to suggest practical strategies to help protect against it or minimise its impact.   

Analysis 

An in-depth analysis of the feedbackdatabase found 76 adverse events associated with fixation , notified between May 2016 and June 2021. These adverse events were always associated with other cognitive biases (four on average). In 28 cases, these adverse events resulted in severe harm to the patient or death. However, the majority (n = 71/76) were considered to have been avoidable or probably avoidable by the notifier. The most effective measures to combat fixation were reassessing the situation, with a break for example, seeking advice from a colleague, or engaging in discussions within the team. 

Surveys of practices were also conducted in 2020 among 1,880 orthopaedic surgeons and in 2021 among 19,483 anaesthetists, surgeons and interventional specialists. Among the 2,961 survey respondents, 61% had already experienced fixation situation (n = 1,891) and 63% had already witnessed it (n = 1,869). 

Risk reduction tools

This PSS proposes a list of solutions to limit the occurrence and consequences of fixation:  

• raise awareness of cognitive function and its shortcomings;  
• ensure a favourable organisational and human context;  
• identify risky situations;  
• mobilise the available tools (alarms, check-lists, protocols, etc.);  

• put into practice a metacognition approach (analysis of reasoning), slow down, take a break;  
• ask for assistance, if necessary (team or colleague).  

For professionals wishing to develop a more detailed understanding of the subject, a table of the main cognitive biases in the healthcare field and a short bibliographic note covering the main concepts relative to cognitive mechanisms have been included in the document.    

This PSS is aimed at all medical and paramedical healthcare professionals, whether they work in the community or in a healthcare facility.