One of the most pervasive blind spots in anesthesia training is the failure to distinguish between protocol and habit.

Protocols are good. They are evidence-based practices designed to improve safety and consistency. Verifying suction, oxygen, and positive pressure at the start of a case is a protocol. So is participating in the surgical time-out.

Habits, on the other hand, can be dangerous. This is especially true in a field where small missteps can lead to serious consequences. A common example of a habit is giving acetaminophen and ketorolac to every patient at the end of a case simply because “that’s what we usually do.”

It’s easy to fall into a “rinse and repeat” cycle during your early months of training, when most cases are straightforward and lend themselves to a familiar sequence of medications. Our therapies are generally safe if used thoughtfully and within the guardrails of proper protocols. But I urge you: resist the comfort of habit. Habits can breed complacency. Habits are a major contributor to drug errors, especially early in your training. “I always do it this way…” or “I didn’t think about it because we always give…”

One of the most important mindsets you can have in anesthesia is this: before giving any drug or performing any procedure, pause and ask yourself: Why? “Why am I doing this? What are the implications for this patient, in this case, at this exact time?”

At some point in your career, you will make a mistake out of habit. Maybe you’ll give rocuronium to someone with a documented allergy. Maybe you’ll perform deep pharyngeal suctioning on a patient who just had a base-of-tongue tumor resection. Or you may give a bag of 10% dextrose instead of Lactated Ringer’s because someone mixed up the fluid bags when re-stocking. After an error, you almost always regret not being more present in the moment and not being more attuned to case-specific details. It will be a hard lesson. We’ve all been there, but we can reduce the risk by being vigilant.

So, before you give a drug or carry out a familiar maneuver, take a breath. Ask yourself:

• Is this right for this patient, right now?
  
• Why am I doing it?
  
• Are there contraindications?
  
• Is there unique anatomy, or are there surgical considerations I need to work around?

Here are some examples of habitual interventions that should always be cross-checked.

• Giving ketorolac without first considering renal function or other potentially co-existing nephrotoxic insults.
  
• Administering rocuronium in simplified unit doses of 50 or 100 mg for an RSI (rapid-sequence induction) dose, when for many smaller patients, this is an enormously unnecessary overdose.
  
• Reflexively administering paralysis to a patient who is bucking the vent, forgetting to pause and consider if this is a case where the patient is undergoing somatosensory evoked potential (SSEP) monitoring. Administering heparin via the wrong route (IV vs subcutaneous), which can vary depending on the type of case (prophylaxis dosing vs vascular intervention dosing).
  
• Many institutions use order-sets for surgical premedications: antibiotics, heparin, enoxaparin, etc. It is still critical for you to cross-check these medications against the case at hand or the patient at hand. For example, suppose most patients getting a gastric sleeve resection at your institution get enoxaparin before incision, but your patient received an epidural, given their history of opioid dependence. In this case, the enoxaparin ordered via order set is no longer appropriate, and you have to be that safety check. Always double-verify medications that are ordered by someone else.
  
• Reaching for airway assistive devices without considering potentially altered anatomy, for example, placing an airway introducer catheter (bougie) into a patient with a known airway lesion, or a nasal trumpet into a patient with coagulopathy or recent nasal surgery. Even in an emergency, you have to carefully consider your interventions.
  
• While habits should be avoided, checklists are extremely beneficial. Over time, you will develop a mental list of things to verify before a case starts, after induction, before incision, and during emergence. When doing so, stay present to the case at hand. In other words, just because an item is on your checklist (nasal temperature probe), does not mean you are obligated to place it in all cases, and perhaps in some cases, it should be avoided entirely.

A deliberate checklist is superior to a routine or habit, because it will avoid what I call the “interrupted routine” error. Imagine that you are on your neuro-anesthesia rotation, and you are used to a certain routine of events after induction: line placement, infusion setup, anti-epileptics, steroids, and mannitol. But suppose on one particular day, your patient has an unexpectedly difficult airway from a large tongue relative to mouth size. After a struggle, you are able to secure the airway and move on with the case. There is a tongue laceration, and some swelling is noted. Throughout the case, you are checking under the drapes to check on the swelling, and you are discussing the possible necessity of delaying extubation. Unbeknownst to you, throughout these events, the surgical team has not placed a Foley because the patient has chronic bladder atony and has nephrostomy tubes in place. However, the nephrostomy tubes are clamped. Hours later, the oversight is realized, and the patient’s bladder becomes critically distended with urine (with mannitol and IV fluid replacement, this could be a very high amount). This is a common source of error: a routine is interrupted in the setting of a complication, and you forget to remain vigilant to other aspects of the case. Having an intraoperative checklist that you periodically run through would avoid your neglect to keep track of I/O (intake/output) parameters.

Another common example of the interrupted routine error involves forgetting to turn on the sevoflurane dial after a difficult intubation. It’s normal to be temporarily stunned by a difficult procedure or an emergent scenario, and this can throw you off from your usual postintubation routine: vent, anesthetic agent, etc. It’s critical to regroup after such an event and go through your usual safety checks.

The discipline of anesthesia lives not in habit, but in deliberate attention. Checklists remind us to think, habits tempt us to stop thinking.