Cognitive Biases and Heuristics in Surgical Settings: A Systematic Review

Objective: This systematic review aimed to identify cognitive biases and heuristics experienced by surgeons in operative settings and the impact these biases and heuristics have on patient care. / Summary Background Data: Cognitive biases and heuristics are systematic errors in thinking that can affect clinical decisions. Both are noted in surgical settings and are a risk to patient safety. / Methods: This review was conducted in accordance with PRISMA guidelines and PROSPERO registered (CRD42023432099). Five major databases were searched from inception to 28th August 2022, with an updated search on 27th January 2024. Original primary research studies in English were included, with relevant risk of bias tools employed for each study. / Results: 21 papers were included. 38 biases were identified across six experiments, five analyses, and ten survey studies. Confirmation bias, anchoring, risk aversion, and overconfidence bias were the most represented. Risk of bias was moderate across most studies. Cognitive biases and heuristics were found to influence surgical outcomes and six studies cited a negative impact on patient care, with one associating biases with fatal outcomes. / Conclusion: Biases and heuristics contribute to surgical errors and never events, and will continue to do so until they are recognised and addressed. Implementing debiasing strategies, such as mindfulness training and deliberate reflection, was found to reduce surgical errors in two studies. This review highlights the need for experimental studies, which are essential for understanding how and why biases lead to negative outcomes and for evaluating further debiasing interventions. We propose directions for future research and system changes.