Deaths by horsekick in the Prussian army - and other ‘Never Events’ in large organisations

Pandit, J J

doi:10.1111/anae.13261

Cited by 30 publications

(28 citation statements)

References 22 publications

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“…Equations represent such a binomial process and thus we would obtain a Poisson probability distribution (to a very good approximation) if we modelled the frequency of the rarer, harmful errors across many trials (a formal mathematical proof of this statement can be found elsewhere ). Moppett and Moppett have reported that Never Events do indeed follow such a Poisson distribution to a good approximation .…”

Section: Discussionmentioning

confidence: 92%

Mathematical model of the risk of drug error during anaesthesia: the influence of drug choices, injection routes, operation duration and fatigue

Sivia¹,

Pandit

2019

Anaesthesia

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The incidence of an anaesthetic drug error can be directly observed in large trials. In an alternative approach, we developed a probabilistic mathematical model in which the anaesthetist is modelled as a 'fallible entity' who makes repeated drug administration choices during an operation. This fallibility was factored in the model as an initial 'intrinsic error rate'. The choices faced included: dose; timing of administration; and the routes available for injection (e.g. venous, arterial, epidural, etc.). Additionally, we modelled the effect of fatigue as a factor that magnifies the cumulative error rate. For an initial intrinsic error rate of 1 in 1000 (which from first principles we consider a reasonable estimate), our model predicted a cumulative probability of error over a~12 h operation of~10%; that is, 1 in 10 operations this long results in some drug error. This is similar to the rate reported by large observational trials. Serious errors constitute a small fraction of all errors; our model predicts a Poisson distribution for the uncommon serious errors, also consistent with independent observations. Even modest assumptions for the development of fatigue had a dramatic and adverse impact on the cumulative error rate. The practice implications of our modelling include: exercising caution or avoiding starting work if under par; added vigilance in unfamiliar environments; keeping anaesthetic recipes simple; and recognising that operation durations > 5-6 h constitute a time of exaggerated risk. These implications are testable predictions in observational trials. If validated, our model could serve as a potential research tool to investigate the impact of safety interventions on the rate of intrinsic error using simulation.

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Section: Discussionmentioning

confidence: 92%

Mathematical model of the risk of drug error during anaesthesia: the influence of drug choices, injection routes, operation duration and fatigue

Sivia¹,

Pandit

2019

Anaesthesia

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“…have not reduced the incidence of wrong side block [1,2]. Stop Before You Block (SBYB) only works if you actually stop immediately before the injection; Mock Before You Block (MBYB) is designed to force the stop moment [3].…”

Section: Mock Before You Block -A Replymentioning

confidence: 99%

“…These include regular audit, awareness campaigns, prominent display of 'Stop Before You Block' (SBYB) posters and advocating verbal confirmation of the block side and site just before needle entry. Despite these measures, wrong site blocks have still occurred, and would seem likely to continue to do so [2,3]. In response to Pandit et al's editorial, we conducted a snap survey of practice amongst 50 anaesthetists (30 consultants, 20 trainees) in our institution.…”

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confidence: 99%

Mock before you block

et al. 2017

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“…Wrong‐site blocks can readily occur in awake patients as the patient may believe that this is the correct way to perform the procedure . Since 2015, the error has been classed by NHS England as a ‘Never Event’, set aside for special consideration and used (albeit perhaps erroneously) as a marker of overall hospital safety and performance . As a focus of regulators, prevention is rightly regarded as a priority.…”

Section: List Of Potential Contributory Factors Involved In Wrong‐sitmentioning

confidence: 99%

“Mock before you block”: an in‐built action‐check to prevent wrong‐side anaesthetic nerve blocks

Pandit¹,

Matthews

Pandit

2016

Anaesthesia

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Deaths by horsekick in the Prussian army - and other ‘Never Events’ in large organisations

Cited by 30 publications

References 22 publications

Mathematical model of the risk of drug error during anaesthesia: the influence of drug choices, injection routes, operation duration and fatigue

Mathematical model of the risk of drug error during anaesthesia: the influence of drug choices, injection routes, operation duration and fatigue

Mock before you block

“Mock before you block”: an in‐built action‐check to prevent wrong‐side anaesthetic nerve blocks

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