Bilateral tension pneumothorax following equipment improvisation.

Respond to unanticipated cues Respond to new information about the patient’s condition Collaborate to solve the problems, ie, chest tubes, ICU admission Table 3. Fixation Error (DeKeyser) Source: DeKeyser V, Woods DD, Masson M, et al. Fixation Errors in Dynamic and Complex Systems: Descriptive Forms, Psychological Mechanisms, Potential Countermeasures. Technical Report for NATO Division of Scientific Affairs. Brussels, Belgium: NATO; 1988. Used with permission. Fixation error: “the persistent failure to revise a diagnosis or plan in the face of readily available evidence that suggests a revision is necessary”