. 2025 Nov;135(5):1499-1510.

doi: 10.1016/j.bja.2025.04.033. Epub 2025 May 29.

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

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

Collaborators, Affiliations

Collaborators

PeDI Collaborative Group:
Benjamin B Bruins¹⁹, Paul Stricker¹⁹, Elizabeth K Laverriere¹⁹, Justin L Lockman¹⁹, Brian Struyk¹⁹, Christopher Ward¹⁹, Akira Nishisaki¹⁹, Ramesh Kodavatiganti¹⁹, Rodrigo J Daly Guris¹⁹, Luis Sequera-Ramos¹⁹, Mark S Teen¹⁹, Ayodele Oke¹⁹, Grace Hsu²⁰, Arul Lingappan²¹, Raymond S Park²², Chinyere Egbuta²², Rhae Battles²¹, Ashley D Bocanegra²¹, Tally Goldfarb²¹, Edgar E Kiss²¹, Peter Szmuk²¹, Sam Mireles²³, Andrea Murray²³, Ranu Jain²⁴, Sabina A Khan²⁴, Christopher Holmes²⁵, Alexander McCann²⁵, Stefano Sabato²⁵, Nicholas Dalesio²⁶, Robert Greenberg²⁶, Sapna Desai²⁶, Angela Lucero²⁷, Charles Schrock²⁸, Jennifer Marsh²⁸, Melissa Brooks Peterson²⁹, Amy Colleen Johnson Lee²⁹, Somaletha Bhattacharya³⁰, Nicholas E Burjek³¹, Sondra Rosander³¹, Sindhu Samba³¹, Narasimhan Jagannathan³², David Lardner³³, Christy Crockett²⁷, Sara Robertson³⁴, Madhankumar Sathyamoorthy³⁴, Franklin Chao³⁵, Jasmine Patel³⁵, Aarti Sharma³⁵, Carolina Pérez-Pradilla³⁶, Neeta Singh³⁷, Brad Taicher³⁸, David Sommerfield³⁹, Neil Hauser³⁹, Hilana Lewkowitz-Shpuntoff⁴⁰, Pilar Castro⁴¹, N Ricardo Riveros Perez⁴¹, Eduardo Vega⁴², Alejandro González⁴², Paola Ostermann⁴², Jonathan Meserve⁴³, Charles Ted Lord⁴³, Fernanda Leite⁴⁴, Kasia Rubin⁴⁴, Songyos Valairucha⁴⁵, Ihab Ayad⁴⁶, Mohamed Rehman⁴⁷, Allison Fernandez⁴⁷, Lillian Zamora⁴⁷, Thanh Tran⁴⁸, Taylor Anspach⁴⁸, Sadiq Shaik⁴⁹, Judit Szolnoki⁴⁹, Preethy J Mathew⁵⁰, Sandhya Yaddanapudi⁵⁰, Indu Sen⁵⁰, Aakriti Gupta⁵⁰, Kathryn Handlogten⁵¹, J Michael Sroka⁵², Vinicius Caldeira Quintao⁵³, Andrew D Weatherall⁵⁴, T Wesley Templeton⁵⁵, Stephen G Flynn⁵⁶, Sydney Nykiel-Bailey¹⁹, Annery G Garcia-Marcinkiewicz⁵⁷, Febina Padiyath⁵⁷, Maria Matuszczak⁵⁸, Raymond S Park⁵⁹, Patrick N Olomu⁶⁰, Kelsey Mitchell⁶⁰

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.
¹⁹ Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
²⁰ Department of Anesthesiology Critical Care Medicine at the Sequera-Ramos and the Keck School of medicine at the University of Southern California, Los Angeles, California, USA.
²¹ Department of Anesthesiology and Pain Management, University of Texas Southwestern and Children's Health System of Texas, Dallas, Texas, USA.
²² Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital of Boston, Harvard Medical School, Boston, Massachussets, USA.
²³ Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California, USA.
²⁴ Department of Anesthesiology, University of Texas Medical School at Houston, Houston, Texas, USA.
²⁵ Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, Australia.
²⁶ Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
²⁷ Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
²⁸ Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri, USA.
²⁹ Department of Anesthesiology, Children's Hospital of Colorado, Aurora, Colorado, USA.
³⁰ Department of Anesthesia, Critical Care and Pain, Massachusetts General Hospital, Boston, Massachussets, USA.
³¹ Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
³² Department of Anesthesiology at Phoenix Children's Hospital, Phoenix, Arizona, USA.
³³ Department of Anesthesiology, Alberta Children's Hospital, Calgary, Alberta, Canada.
³⁴ Department of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi, USA.
³⁵ Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York, USA.
³⁶ Department of Anesthesia. Hospital Universitario Fundacion Santa Fe de Bogotá., Bogotá D.C., Colombia.
³⁷ Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, New York, USA.
³⁸ Department of Anesthesiology, Duke University, Durham, North Carolina, USA.
³⁹ Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Nedlands, Australia, Institute for Paediatric Perioperative Excellence, The Universtiy of Western Australia, Perth, Australia, Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Australia, and Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, Australia.
⁴⁰ Department of Anesthesiology, Montefiore Medical Center, New York, New York, USA.
⁴¹ Department of Anesthesiology and Pain Management, Children's Hospital of Cleveland Clinic, Cleveland, Ohio, USA.
⁴² Department of Anesthesia, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.
⁴³ Department of Anesthesiology, Maine Medical Center, Portland, Maine, USA.
⁴⁴ Hospital de Reabilitação de Anomalias Craniofaciais (HRAC-USP) Bauru, São Paulo, Brazil.
⁴⁵ Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Medical Center, Washington, District of Columbia, USA.
⁴⁶ Department of Anesthesiology, Penn State Health Hershey Medical Center, Stage College, Pennsylvania, USA.
⁴⁷ Department of Anesthesia, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA.
⁴⁸ Department of Anesthesiology and Pain Medicine, UC Davis Children's Hospital, Davis, California, USA.
⁴⁹ Department of Anesthesiology, The Nemours Foundation, Orlando, Florida, USA.
⁵⁰ Department of Anaesthesia & Intensive Care, PGIMER, Chandigarh, India.
⁵¹ Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
⁵² Arnold Palmer Hospital for Children, Orlando, Florida, USA.
⁵³ Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
⁵⁴ The Children's Hospital at Westmead, Sidney, Australia.
⁵⁵ Department of Anesthesiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, Charlotte, North Carolina, USA.
⁵⁶ Department of Anesthesiology, Washington University in St. Louis School of Medicine, St Louis, Missouri, USA.
⁵⁷ Department of Anesthesiology, Critical Care, and Pain Medicine, McGovern Medical School at UT Health, Texas Medical Center Houston, Houston, Texas, USA.
⁵⁸ Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachussets, USA.
⁵⁹ Department of Anesthesia, University of Iowa Stead Family Children's Hospital, Iowa city, Iowa, USA.
⁶⁰ Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.

PMID: 40447486
PMCID: PMC12597392
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

Martina Bordini et al. Br J Anaesth. 2025 Nov.

. 2025 Nov;135(5):1499-1510.

doi: 10.1016/j.bja.2025.04.033. Epub 2025 May 29.

Authors

Collaborators

PeDI Collaborative Group:
Benjamin B Bruins¹⁹, Paul Stricker¹⁹, Elizabeth K Laverriere¹⁹, Justin L Lockman¹⁹, Brian Struyk¹⁹, Christopher Ward¹⁹, Akira Nishisaki¹⁹, Ramesh Kodavatiganti¹⁹, Rodrigo J Daly Guris¹⁹, Luis Sequera-Ramos¹⁹, Mark S Teen¹⁹, Ayodele Oke¹⁹, Grace Hsu²⁰, Arul Lingappan²¹, Raymond S Park²², Chinyere Egbuta²², Rhae Battles²¹, Ashley D Bocanegra²¹, Tally Goldfarb²¹, Edgar E Kiss²¹, Peter Szmuk²¹, Sam Mireles²³, Andrea Murray²³, Ranu Jain²⁴, Sabina A Khan²⁴, Christopher Holmes²⁵, Alexander McCann²⁵, Stefano Sabato²⁵, Nicholas Dalesio²⁶, Robert Greenberg²⁶, Sapna Desai²⁶, Angela Lucero²⁷, Charles Schrock²⁸, Jennifer Marsh²⁸, Melissa Brooks Peterson²⁹, Amy Colleen Johnson Lee²⁹, Somaletha Bhattacharya³⁰, Nicholas E Burjek³¹, Sondra Rosander³¹, Sindhu Samba³¹, Narasimhan Jagannathan³², David Lardner³³, Christy Crockett²⁷, Sara Robertson³⁴, Madhankumar Sathyamoorthy³⁴, Franklin Chao³⁵, Jasmine Patel³⁵, Aarti Sharma³⁵, Carolina Pérez-Pradilla³⁶, Neeta Singh³⁷, Brad Taicher³⁸, David Sommerfield³⁹, Neil Hauser³⁹, Hilana Lewkowitz-Shpuntoff⁴⁰, Pilar Castro⁴¹, N Ricardo Riveros Perez⁴¹, Eduardo Vega⁴², Alejandro González⁴², Paola Ostermann⁴², Jonathan Meserve⁴³, Charles Ted Lord⁴³, Fernanda Leite⁴⁴, Kasia Rubin⁴⁴, Songyos Valairucha⁴⁵, Ihab Ayad⁴⁶, Mohamed Rehman⁴⁷, Allison Fernandez⁴⁷, Lillian Zamora⁴⁷, Thanh Tran⁴⁸, Taylor Anspach⁴⁸, Sadiq Shaik⁴⁹, Judit Szolnoki⁴⁹, Preethy J Mathew⁵⁰, Sandhya Yaddanapudi⁵⁰, Indu Sen⁵⁰, Aakriti Gupta⁵⁰, Kathryn Handlogten⁵¹, J Michael Sroka⁵², Vinicius Caldeira Quintao⁵³, Andrew D Weatherall⁵⁴, T Wesley Templeton⁵⁵, Stephen G Flynn⁵⁶, Sydney Nykiel-Bailey¹⁹, Annery G Garcia-Marcinkiewicz⁵⁷, Febina Padiyath⁵⁷, Maria Matuszczak⁵⁸, Raymond S Park⁵⁹, Patrick N Olomu⁶⁰, Kelsey Mitchell⁶⁰

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.
¹⁹ Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
²⁰ Department of Anesthesiology Critical Care Medicine at the Sequera-Ramos and the Keck School of medicine at the University of Southern California, Los Angeles, California, USA.
²¹ Department of Anesthesiology and Pain Management, University of Texas Southwestern and Children's Health System of Texas, Dallas, Texas, USA.
²² Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital of Boston, Harvard Medical School, Boston, Massachussets, USA.
²³ Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California, USA.
²⁴ Department of Anesthesiology, University of Texas Medical School at Houston, Houston, Texas, USA.
²⁵ Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, Australia.
²⁶ Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
²⁷ Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
²⁸ Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri, USA.
²⁹ Department of Anesthesiology, Children's Hospital of Colorado, Aurora, Colorado, USA.
³⁰ Department of Anesthesia, Critical Care and Pain, Massachusetts General Hospital, Boston, Massachussets, USA.
³¹ Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
³² Department of Anesthesiology at Phoenix Children's Hospital, Phoenix, Arizona, USA.
³³ Department of Anesthesiology, Alberta Children's Hospital, Calgary, Alberta, Canada.
³⁴ Department of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi, USA.
³⁵ Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York, USA.
³⁶ Department of Anesthesia. Hospital Universitario Fundacion Santa Fe de Bogotá., Bogotá D.C., Colombia.
³⁷ Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, New York, USA.
³⁸ Department of Anesthesiology, Duke University, Durham, North Carolina, USA.
³⁹ Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Nedlands, Australia, Institute for Paediatric Perioperative Excellence, The Universtiy of Western Australia, Perth, Australia, Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Australia, and Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, Australia.
⁴⁰ Department of Anesthesiology, Montefiore Medical Center, New York, New York, USA.
⁴¹ Department of Anesthesiology and Pain Management, Children's Hospital of Cleveland Clinic, Cleveland, Ohio, USA.
⁴² Department of Anesthesia, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.
⁴³ Department of Anesthesiology, Maine Medical Center, Portland, Maine, USA.
⁴⁴ Hospital de Reabilitação de Anomalias Craniofaciais (HRAC-USP) Bauru, São Paulo, Brazil.
⁴⁵ Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Medical Center, Washington, District of Columbia, USA.
⁴⁶ Department of Anesthesiology, Penn State Health Hershey Medical Center, Stage College, Pennsylvania, USA.
⁴⁷ Department of Anesthesia, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA.
⁴⁸ Department of Anesthesiology and Pain Medicine, UC Davis Children's Hospital, Davis, California, USA.
⁴⁹ Department of Anesthesiology, The Nemours Foundation, Orlando, Florida, USA.
⁵⁰ Department of Anaesthesia & Intensive Care, PGIMER, Chandigarh, India.
⁵¹ Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
⁵² Arnold Palmer Hospital for Children, Orlando, Florida, USA.
⁵³ Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
⁵⁴ The Children's Hospital at Westmead, Sidney, Australia.
⁵⁵ Department of Anesthesiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, Charlotte, North Carolina, USA.
⁵⁶ Department of Anesthesiology, Washington University in St. Louis School of Medicine, St Louis, Missouri, USA.
⁵⁷ Department of Anesthesiology, Critical Care, and Pain Medicine, McGovern Medical School at UT Health, Texas Medical Center Houston, Houston, Texas, USA.
⁵⁸ Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachussets, USA.
⁵⁹ Department of Anesthesia, University of Iowa Stead Family Children's Hospital, Iowa city, Iowa, USA.
⁶⁰ Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.

PMID: 40447486
PMCID: PMC12597392
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.

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Conflict of interest statement

Declarations of interest PGD is a member and Chair of the Quality and Safety Committee at Society for Pediatric Anesthesia (no payment involved). PK is in the Anesthesia Patient Safety Foundation (APSF) commissioned and international Patient Safety Priority (PSP) Advisory Group on Airway Management (no payment involved). AH: Verathon Inc. and the American College of Osteopathic Anesthesiologists (consulting fees) and has an uncompensated leadership role in the Society for Pediatric Anesthesiologist Difficult Intubation SIG. ACL received a one-time honorarium for a chapter in Current Reviews in Clinical Anesthesia. BSvUS: NHMRC, Australia, Stan Perron Charitable Foundation, Perth, Australia (payments to institutions for independent research funds). JP received compensation for writing a chapter in Wolters Kluwer Health publisher of Barash, Cullen, and Stoelting's Clinical Anesthesia. The other authors declare that they have no conflicts of interest.

Figures

**Fig 1**
Methods for inferring cognitive errors during clinical care. (a) Study design showing how cognitive errors may be inferred retrospectively by linking observed and recorded clinical endpoints (e.g. number of airway device attempts; device used) to preceding actions. (b) Multiple methods can enhance inference of cognitive errors in airway management, including clinical data, external observation, video-audio recordings, and post-event interviews. Dashed red arrows indicate inference rather than direct measurement. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

**Fig 2**
Study flowchart. PeDI, Pediatric Difficult Intubation.

**Fig 3**
Cognitive errors in study population. Proportion of cases with at least one cognitive error by number of intubation attempts (a), by year (b), and by first-attempt provider (c). Stacked bars represent the total number of cases at each category level, segmented by the presence or absence of cognitive errors. Line plots indicate the proportion of cases with at least one cognitive error, mapped to the secondary y-axis. The proportion of cognitive errors increased with a greater number of intubation attempts. Variation was observed across years and provider types, with the highest proportion among cases initiated by ‘Other specialists’ and the lowest among anaesthesia assistants. CRNA, certified registered nurse anaesthetist; ENT, otolaryngology (ear, nose, and throat).

**Fig 4**
Multivariable mixed-effects logistic regression analysis of adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for cognitive errors, complications, and severe complications. Data are presented for both all patients and children <5 kg. Each plot represents the adjusted ORs for the presence of at least one cognitive error (a and b), any complications (c and d), and severe complications (e and f). The x-axis is displayed on a logarithmic scale, with the OR of 1.00 (representing no effect) marked in the centre, and CIs indicated by the black horizontal lines. The x-axis range is set from 0.1 to 50 to capture the full range of adjusted odds ratios. CRNA, certified registered nurse anaesthetist; ENT, otolaryngology (ear, nose, and throat); PeDI, Pediatric Difficult Intubation.

See this image and copyright information in PMC

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

Collaborators

Affiliations

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

Authors

Collaborators

Affiliations

Abstract

Conflict of interest statement

Figures

References

MeSH terms

LinkOut - more resources

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