An Analysis of Major Errors and Equipment Failures in Anesthesia Management

Medication safety in anesthetic practice: first do no harm

“…If patient safety is defined as freedom from accidental injury, then several studies suggest that medication error has become a leading cause of adverse events during anesthesia. For example, an analysis of critical incidents by Cooper et al , (1978 and1984) demonstrated that the total number of medication-related events (including syringe swaps, drug ampoule swaps, overdose, or wrong choice of drug) far exceeded the next most frequent problem, disconnection of the breathing circuit. 2,3 Similarly, an analysis of the first 2,000 events reported to the Australia Incident Monitoring Study (AIMS) revealed that the "wrong drug" was a common problem.…”

“…, (1978 et 1984) a démontré que le nombre total d'incidents reliés à la médication (y compris l'échange de seringue, d'ampoule, la surdose ou le mauvais choix de médicament) excède de loin le deuxième problème qui se présente fréquemment, l'interruption du circuit respiratoire. 2,3 De même, une analyse des 2 000 premiers incidents rapportés par l'Australia Incident Monitoring Study (AIMS) a révélé que le "mauvais médicament" a représen -té le problème le plus fréquent. 4 De multiple facteurs contribuent à l'augmentation des risques d'erreurs de médication chez les patients qui subissent une anesthésie.…”

Patient Monitoring Alarms in the ICU and in the Operating Room

“…Cooper e t al. showed in the 1980s that 70 % of all anesthesia-related critical incidents were caused by human error [7]. Similar da ta are available from the aviation industry [8].…”

Ocorrências Iatrogênicas Na Uti E O Enfoque De Qualidade

“…Analisando-se os dados apresentados na literatura, verificase que o fator humano é apontado como o principal agente causador das ocorrências iatrogênicas ou incidentes críticos (20,(26)(27)(28)(29) . No entanto, embora grande porcentagem dos problemas tenha o componente humano envolvido, sua contribuição global para muitos problemas deve ser analisada.…”