When Cognitive Error Hits the Paediatric Airway
You’re on a busy shift when a 3-year-old with severe pneumonia arrives in resus. She’s hypoxic despite high-flow oxygen and tiring quickly. The decision is made to intubate.
You brief the team, drugs are drawn up, and equipment is checked.
First attempt shows a limited view. You adjust positioning and optimise.
The second attempt is still difficult. The saturations begin to fall.
Someone calls out, “Sats are 84%.”
You feel you were close that time. Just a slightly better view and you’ll get it. You go again…
Afterwards, during the debrief, someone asks, “Should we have switched strategy sooner?”
On reflection, you see that you should have, but why didn’t it occur to you at the time?
In situations like this, it’s easy to blame our technique, the equipment or the anatomy. What we think about less often is the role of cognitive error- the predictable ways our thinking can become narrowed or biased under pressure.
A recent study analysed the Paediatric Difficult Intubation Registry (PeDI) and found that cognitive errors occurred in nearly one in five difficult paediatric airway encounters, and when they did, complication rates were higher.
In this post, we’ll unpack what we mean by cognitive error, explore the PeDI study, and, most importantly, consider what this means for us in paediatric emergency care.
What is cognitive error?
Cognitive error refers to predictable distortions in thinking that influence judgement and decision-making, particularly under pressure. In healthcare, these errors rarely stem from a lack of knowledge or technical skill; rather, they arise from how our brains process information under stress.
Some common examples include:
Fixation error – “I can still get this.”
This involves persisting with a plan despite clear signs it’s not working. In a paediatric airway, this often looks like repeated intubation attempts and a failure to recognise the need to move to an alternative plan.
Overconfidence bias – “I’ve done this loads of times.”
This is an inflated belief in our ability that delays escalation or seeking help. Experience is invaluable, but overconfidence can sometimes lead to not changing the operator or not calling for help early enough.
Confirmation bias – “See? It’s improving.”
This is when we focus on reassuring signs while ignoring contradictory information. A brief improvement in saturations may overshadow rising carbon dioxide or poor chest movement.
Omission bias – “What if I make it worse?”
This occurs when we avoid action because the harm from doing something feels more uncomfortable than the harm of doing nothing. In airway emergencies, this may mean delaying escalation or decisive intervention for fear of getting it wrong.
In paediatrics, margins are small, and deterioration is fast. If we don’t understand how pressure shapes our thinking, we won’t spot it happening in ourselves or in our teams. And if we don’t recognise it, we can’t interrupt it.
With this in mind, we turn to a recent study that specifically examines how cognitive errors influence management of challenging paediatric airways:
Bordini, Martina et al. “Incidence of cognitive errors in difficult airway management: an inference human factors study from the Paediatric Difficult Intubation Registry.” British Journal of Anaesthesia vol. 135,5 (2025): 1499-1510.
Why was this study needed?
Human factors research has consistently demonstrated that cognitive errors contribute to failure in high-risk industries such as aviation and nuclear power. In emergency medicine, however, the role of cognitive bias has been far less systematically explored.
Although difficult airway guidelines emphasise non-technical skills such as situational awareness, communication, and escalation, the true impact of cognitive error in paediatric difficult airway management has not previously been quantified.
The authors therefore aimed to determine:
- How often cognitive errors occur during difficult paediatric intubation
- Whether their presence is associated with adverse outcomes
Who were the patients?
They obtained data from the PeDI Registry, an international multicentre registry capturing difficult paediatric airway encounters across tertiary centres.
The study included children who required three or more intubation attempts over a 12-year period.
The rationale for using three attempts was that cognitive error was thought to be more likely to manifest after initial technical factors (e.g., positioning, equipment) had been addressed.
What was the intervention?
There was no intervention in this retrospective observational study.
What were the outcomes measured?
The primary outcome was the overall incidence of cognitive error.
Secondary outcomes included:
- Incidence of specific cognitive error subtypes
- Association with patient and clinician factors
- Relationship between cognitive error and complication
What were the results?
Out of 2,801 difficult airway encounters, cognitive error was identified in 487 cases (17.4%).
Fixation error was the most common error type (11.5%), followed by omission bias (5.9%).
They also found that complications occurred more with cognitive error than without occurring in:
- 39.8% of cases with cognitive error
- 25.5% of cases without cognitive error
The results also showed that multiple cognitive errors were associated with an even higher risk of complications (adjusted odds ratio, 2.87).
What did the authors conclude from these results?
They concluded that, as cognitive errors during paediatric airway management are common and have been shown to be associated with an increased incidence of complications, efforts should be made to reduce these errors.
But how good is this paper?
As always, critical analysis of this paper is essential to understand how we can apply this evidence to our practice. Let’s take a closer look using a CASP checklist:
Did the study address a clearly focused question?
Yes. The authors clearly defined their exposure (cognitive error) and outcome (complications) within a specific population.
Was the cohort recruited in an acceptable way?
Yes. Data were drawn from a well-established international registry with consent, although participation is voluntary, introducing potential selection bias.
Was the exposure (cognitive error) accurately measured?
This is the most significant challenge to this methodology.
Cognitive errors were inferred retrospectively using predefined clinical endpoints, rather than direct observation or debriefing.
Because cognitive bias is an internal mental process, there is no way to say for sure with this method whether a cognitive error occurred, introducing the possibility of misclassification bias.
Was the outcome accurately measured?
Yes. Complications (including severe complications) were objectively defined using registry data, reducing reporting bias and increasing clinical relevance. However, the registry data depend on accurate documentation, thereby introducing the risk of reporting bias and variability in reporting between centres.
Have important confounding factors been considered?
Yes, reasonably well. The authors adjusted for key variables, including age, weight, clinician type and experience, emergent cases, and number of attempts, using multivariable models with centre clustering. However, unmeasured factors such as team dynamics and situational context remain potential confounders.
Was the follow-up complete?
Yes. As an intubation encounter dataset, outcomes occurred within the procedure episode and were captured in the registry.
Do the results fit with other evidence?
This study was the first of its kind looking at cognitive error specifically in paediatric airway, so there is none to directly compare with.
Overall validity and applicability
The study provides useful evidence that cognitive errors are present and clinically relevant in paediatric difficult airway management. Limitations include indirect measurement of cognitive bias and restricted generalisability beyond tertiary airway centres.
The Bottom Line
This study highlights an important and often under-recognised human factors issue in paediatric airway management.
Its strengths include its large, multicentre dataset and clinically relevant outcomes.
While the retrospective design and indirect identification of cognitive error introduce potential bias, the findings are difficult to ignore.
Cognitive errors appear to occur commonly during difficult paediatric airway encounters, and their presence is associated with increased complication rates. If we fail to address them, harm is likely to follow.
So how can we address cognitive errors in practice?
Human factors research consistently shows that even experienced clinicians are vulnerable to predictable cognitive errors, particularly in high-stress situations.
Simply telling ourselves to “try harder” or “be more careful” is ineffective. Cognitive bias is not a failure of our own diligence; rather, it is a normal feature of human cognition under pressure.
Luckily, the reassuring message from human factors research is that practical strategies can reduce risk and can be directly applied to paediatric airway management. Some examples are…
Pre-commitment strategies
Cognitive forcing strategies are designed to interrupt fixation and automatic thinking (7). In practice, this means using preparation time to agree limits as a team, for example;
“If two attempts fail, we change operator.”
By agreeing on thresholds in advance, we reduce the likelihood of persisting with a failing plan due to fixation bias.
Cognitive offloading
Research shows that working memory is limited and that stress impairs decision-making capacity.
During paediatric intubation, cognitive load is high. Checklists, cognitive aids, clear role allocation and verbal prompts help offload mental burden, saving brain capacity for recognising deterioration and changing strategy.
Flattening the hierarchy
Communication and psychological safety are strongly associated with improved team performance. Creating an environment where team members feel able to speak up provides a real-time defence against cognitive bias.
“We’ve had a number of unsuccessful attempts now- I think we need to change strategy”
In moments of tunnel vision, your team is your greatest defence, helping you step back and see the wider picture. Everyone in the room should feel both comfortable and empowered to redirect the plan when needed.
Simulation beyond technical skill
Simulation should train more than technique and knowledge. We need to ensure that we’re practising escalation decisions, communication under pressure, and recognising where our cognition fails. Only through practice and reflection can we become more attuned to the patterns of our thinking under pressure.
You may already use some of these strategies in your practice, but it’s worth considering how you can embed others into your everyday work. Deliberately adopting even one of these approaches can help protect your thinking and be kinder to your mind the next time you find yourself under pressure.
Take home message:
When preparing for difficult paediatric airways we need to practice not only our technique and knowledge but our cognition under pressure.
Cognitive errors are common, even among experienced clinicians, and reflect predictable human responses to stress rather than individual weakness.
The bottom line is that we need to anticipate errors, find practical ways to recognise them and work as a team to minimise them. Recognising cognitive error in the moment can be just as vital as the technical skill of intubation itself.
References
Bordini M, Orsini L, Li SYW, et al. Incidence of cognitive errors in difficult airway management: an inference human factors study from the Pediatric Difficult Intubation Registry. Br J Anaesth. 2025;135(5):1499-1510. doi:10.1016/j.bja.2025.04.033
Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002;9:1184-1204. doi:10.1111/j.1553-2712.2002.tb01574.x
Stiegler MP, et al. Cognitive errors detected in anaesthesiology: a literature review and pilot study. Br J Anaesth. 2012;108(2):229-235.
Velazquez J. The presence of behavioral traps in US airline accidents: a qualitative analysis. Safety. 2018;4(1):2.
Ahmad I, et al. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Br J Anaesth. 2025;136(1):283-307.
Hall C, Robertson D, Rolfe M, et al. Do cognitive aids reduce error rates in resuscitation team performance? Trial of emergency medicine protocols in simulation training (TEMPIST) in Australia. Hum Resour Health. 2020;18:1. doi:10.1186/s12960-019-0441-x
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780. doi:10.1097/00001888-200308000-00003
Roth E, Mumaw R, Lewis P. An empirical investigation of operator performance in cognitively demanding simulated emergencies. Washington (DC): Nuclear Regulatory Commission; 1994.
Edmondson AC. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350-383.
Bond WF, Deitrick LM, Arnold DC, Kostenbader M, Barr GC, Kimmel SR, Worrilow CC. Using simulation to instruct emergency medicine residents in cognitive forcing strategies. Acad Med. 2004;79(5):438-446. doi:10.1097/00001888-200405000-00014
