Error Traps in Developing a Pediatric Enhanced Recovery After Surgery (ERAS) Program
Myron Yaster MD, Megan Brockel MD, Lynn Martin MD MBA
Today’s PAAD by Taylor et al.1 is yet another article in the error trap series published in the Journal Pediatric Anesthesia. What is an error trap? “Cognitive errors, a subset of medical errors involving faulty-thought processes and subconscious biases, are important contributors to missed diagnoses and patient injury. Indeed, most medical errors are mistakes in thinking and not procedural or technical mistakes.”2 What are some common cognitive errors? Stiegler et al.2 identify 14 including: anchoring (focusing on one issue at the expense of understanding the whole situation), availability bias (choosing a diagnosis because it is in the forefront of your mind due to an emotionally charged memory of a bad experience,) confirmation bias (seeking or acknowledging only information that confirms the desired or suspected diagnosis), premature closure (accepting a diagnosis prematurely, failure to consider reasonable differential of possibilities), overconfidence bias (inappropriate boldness, not recognizing the need for help, tendency to believe we are infallible), framing effect (subsequent thinking is swayed by leading aspects of initial presentation), commission bias (tendency toward action rather than inaction, performing maneuvers that are not indicated, deviating from protocol—may be due to overconfidence, desperation, or pressure from others), to name just a few. This paper by Stiegler et al. is so foundationally important to this topic that we will review it as separate PAAD in the next couple of weeks, even though it was published almost a decade ago.
Today’s PAAD is ostensibly about error traps in developing a pediatric Enhanced Recovery After Surgery (ERAS) program. It would have been better titled, “how to implement an ERAS program in your institution”. Indeed, as Taylor et al. state: “This article aims to explore common challenges in pediatric ERAS development and implementation, along with strategies to avoid potential pitfalls. Key themes include departmental and institutional support, stakeholder engagement, awareness of pathways, data management and dissemination, and long-term maintenance including Plan-Do-Study-Act (PDSA) cycles. Pathway development teams should be aware of these considerations and potential pitfalls, and focusing on them can promote long-term success for a well-designed pathway.”1 We’ve discussed ERAS in many previous PAADs. I’ve asked Dr. Megan Brockel and Dr. Lynn Martin who leads the PAAD’s implementation science reviews to assist. Myron Yaster MD
Original article
Taylor CM, Weisberg EL, Doyle NM, Glenski TA. Error Traps in Developing a Pediatric Enhanced Recovery After Surgery (ERAS) Program. Paediatr Anaesth. 2025 Mar;35(3):199-206. doi: 10.1111/pan.15042. Epub 2024 Nov 23. PMID: 3957900
“Enhanced recovery after surgery (ERAS) pathways aim to promote a faster recovery after surgery without increasing adverse effects for patients through a multidisciplinary approach. The creation and implementation of these pathways require a team-based culture that includes patients and their families. Developing an ERAS culture in a hospital or department takes more than just writing protocols, and barriers to implementation are perceived differently depending on one's role within the team. Some of these barriers include lack of organizational support, poor leadership skills, poor communication, lack of time for patient education, lack of buy-in, and resistance to change current practice.”1 We would assert that these barriers are not limited to ERAS protocols, but to many process improvement changes introduced into your practice and we’ve discussed quality improvement implementation science in many previous PAADs. Examples include implementing opioid-free anesthesia for your T&A patients, reducing your institution’s carbon footprint, and thinking about and ensuring individual and system-wide adherence to surgical site prophylaxis. Further, we would argue that having and using real-time data for monitoring and facilitating learning is essential in any process improvement.
Kotter’s eight-step model of change is the “bible” of process improvement and implementation.3 The key steps included creating a sense of urgency, building a coalition, developing a strategy, communicating the vision, enabling personnel to enact change, generating short-term wins, sustaining wins in order to produce bigger results, and embedding the changes into the culture.
Taylor et al. highlight 5 key error traps in their article:
Failure to address existing cultural framework and obtain institutional support for change toward evidence-based and/or best practice
Failure to engage key stakeholders
Failure to inform and educate frontline healthcare workers on ERAS pathway eligibility and details
Failure to accurately collect, recognize, and correct deficiencies in data
Lack of ongoing ERAS pathway maintenance, including identifying barriers and monitoring outcomes to improve implementation and sustain change
The PAADs are 5-6 minute reads by design, so it is beyond the scope of the PAAD to discuss all these error traps in our review. Because we think data collection is the key to implementation science, we will limit our discussion to error trap 5:
“After all the significant amount of time, effort, and multidisciplinary collaboration that are involved in creating and releasing an ERAS pathway, the quickest way to ensure that the pathway fails over time is to not maintain the pathway and disregard the stakeholders. The pathway is a “living document” that requires regular inputs of time, energy, and resources for it to survive and succeed. While the pathway is a mechanism to change and improve processes of care, the creators (owners) must focus efforts to ensure that the standards are being followed (compliance), results are measured and communicated (data sharing), challenges are identified, and ideas for improvement are considered (360° feedback). Appointing a champion (owner) for each ERAS pathway can help continue to drive work within the pathway. Regularly scheduled meetings and updates should continue within the team, especially as data become robust. Since all ERAS pathways are multidisciplinary, it is vital that each discipline continues to be engaged. Obtaining feedback from front-line staff is important, not just from the ERAS team, but from any stakeholders who may interact and care for an ERAS patient. Feedback will assist in identifying barriers to bundle compliance and uncovering further opportunities for improvement that address these barriers. After each PDSA cycle has been completed and changes to a pathway are made, regular (routine) communication back to all stakeholders and staff is important. In addition to communicating what changes are made, it is equally important to explain why the changes were made, preferably supported by data.”1
“Like all quality improvement projects, the work does not stop after implementation. The team must understand that ERAS pathways require PDSA cycles and continuous participation of all stakeholders. Sustaining the positive momentum following the release of an ERAS pathway requires commitment and diligence, but is necessary for the long-term success and sustainability.” 1 Let me (LDM) illustrate with data from Seattle Children’s ASC where an ERP was launch several years ago.4 Our team found barriers in reliable, effective (i.e., therapeutic serum levels at the start of surgery), large scale (all patients) acetaminophen intake at the surgery center. They implemented home administration immediately prior to departure for ASC by the parents and tracked results. Approximately 70% of parents have been able to follow these instructions, now sustained for more than 2 years. Not shown are the additional 20% of patients who do receive acetaminophen in the ASC prior to surgery because it was not offered at home. The remaining 10% typically refuse the pre-medication at home and ASC. Not shown are equity (language) difference in home compliance that remains an active opportunity for further improvement.
Please share your ERAS success or failure stories, thoughts, and comments with Myron who will post in a Friday Reader Response.
References
1. Taylor CM, Weisberg EL, Doyle NM, Glenski TA. Error Traps in Developing a Pediatric Enhanced Recovery After Surgery (ERAS) Program. Paediatric Anaesthesia 2025;35(3):199-206. (In eng). DOI: 10.1111/pan.15042.
2. Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Cognitive errors detected in anaesthesiology: a literature review and pilot study. British Journal of Anaesthesia 2012;108(2):229-35. (In eng). DOI: 10.1093/bja/aer387.
3. Kotter JP. Leading Change. Boston, MA: Harvard Business School Press, 1996.
4. Martin LD, Chiem JL, Hansen EE, et al. Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesth Analg. 2022;135(6):1271-1281. DOI: 10.121/ANE.0000000000006256 (PMID: 36384014)