An Analysis of Major Errors and Equipment Failures in Anesthesia Management

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Abstract
Adaptations of the critical-incident technique were used to gather reports of anesthesia-related human error and equipment failure. A total of 139 anesthesiologists, residents and nurse-anesthetists from 4 hospitals participated as subjects in directed or open-ended interviews and 48 of them functioned as trained observers. A total of 1089 descriptions of preventable critical incidents were collected. Of these, 70 represented errors or failures that had contributed in some way to a substantive negative outcome. From these incidents, 10 potential strategies were developed for prevention or detection of incidents. Overall patterns observed in this study were similar to those of an earlier report. The incidents most frequently reported including breathing circuit disconnections, drug-syringe swaps, gas-flow control errors and losses of gas supply. Only 4% of the incidents with substantive negative outcomes involved equipment failure, confirming the previous impression that human error is the dominant issue in anesthesia mishaps. Among the broad categories of key strategies for mishap prevention were additional technical training, improved supervision, improved organization, equipment human-factors improvements and use of additional monitoring instrumentation. Less healthy patients are more likely to be affected adversely by errors. In future studies of anesthesia mortality and morbidity, untoward events should be classified according to preventive strategy rather than outcome alone as an aid to those who wish to apply the experience of others to lessen the risk in their individual practice.

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