Human factors in pediatric anesthesia incidents

Marcus, R.

doi:10.1111/j.1460-9592.2005.01771.x

Cited by 71 publications

(68 citation statements)

References 18 publications

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“…(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17) The average annual rate of critical incident reporting at our hospital is 3%-4% (Fig. 2), and this percentage has remained stable through the years despite an increase in patient numbers.…”

Section: Discussionmentioning

confidence: 99%

Audits and critical incident reporting in paediatric anaesthesia: lessons from 75,331 anaesthetic

Wan¹,

Siow²,

Lee³

et al. 2013

SMedJ

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INTRODUCTIONThis study reports our experience of audit and critical incidents observed by paediatric anaesthetics from 2000 to 2010 at a paediatric teaching hospital in Singapore.METHODS Data pertaining to patient demographics, practices and critical incidents during anaesthesia and in the perioperative period were prospectively collected via an audit form and retrospectively analysed thereafter.RESULTS A total of 2,519 incidents were noted at the 75,331 anaesthetics performed during the study period. There were nine deaths reported. The majority of incidents reported were respiratory critical incidents (n = 1,757, 69.8%), followed by cardiovascular incidents (n = 238, 9.5%). Risk factors for critical incidents included age less than one year, and preterm and former preterm children.CONCLUSION Critical incident reporting has value, as it provides insights into the system and helps to identify active and system errors, thus enabling the formulation of effective preventive strategies. By creating and maintaining an environment that encourages reporting, we have maintained a high and consistent reporting rate through the years. The teaching of analysis of critical incidents should be regarded by all clinicians as an important tool for improving patient safety.

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Section: Discussionmentioning

confidence: 99%

Audits and critical incident reporting in paediatric anaesthesia: lessons from 75,331 anaesthetic

Wan¹,

Siow²,

Lee³

et al. 2013

SMedJ

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show abstract

“…The background of the study was reported adverse events where some contributing factors had been identified as lack of appropriate airway management equipment and wrong use of or missing medications. Most anaesthesiologist will recognise such events in their clinical practice [111,112]. In 2007, we were not able to identify a validated methodology to develop and design specific medical safety checklists from previously published studies.…”

Section: Methodological Considerations and Ethics Validitymentioning

confidence: 98%

Implementation of safety checklists in medicine: not as simple as it sounds

Thomassen

2012

Acta Anaesthesiol Scand

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“…There are also taxonomies for particular aspects of practice such as medication error 26,27 or particular kinds of errors within particular areas of practice such as anaesthetic human errors. 28 The work of Reason provides a sound theoretical base for conceptualising and managing error. 1,6,7,9,10,[29][30][31][32][33][34][35][36] However, the need remains for research that can better contribute to the theorisation of hospital error in ways that are useful to policy and practice.…”

Section: Evidence-based Theorisation Useful To Policy and Practicementioning

confidence: 99%

Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance?

Bell

2007

Aust. Health Review

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This paper aims to provide hospital administrators and others making decisions about hospital error funding, as well as researchers, with information about what good hospital error research looks like. It offers a selective review of how the error literature has approached hospital error, which is used to develop five criteria for sound hospital error research. It also explores the potential for better hospital error research of quali-quantitative analysis (QQA), an innovative social sciences research method. In a context in which other methodologies all have their shortcomings, QQA appears to go some way toward meeting the five criteria for sound hospital error research. Ideally, QQA would be used in combination with other approaches to answer the kinds of questions that are important to hospital administrators when they are faced with high-stakes CONSIDERABLE MEDIA AND POLICY attention is given to the high stakes "unusual cases" (such as error and/or professional misconduct) in hospital service delivery. But how can hospital administrators and policy decision makers prevent such cases from happening in the first place? This paper describes the research methods that have been used to understand hospital error. It also explores the potential of a transdisciplinary research method (quali-quantitative analysis[QQA]) for understanding hospital error and its causes, particularly in small-N studies.Without sound practices for investigating and preventing errors, the most accurate and full error reporting systems are meaningless. Knowledge about what works and what doesn't in error research methodology is critical to managing error. Accordingly, this paper aims to provide information and criteria for deciding on the kind of study of hospital error likely to deliver sound evidence for policy and practice. The paper should also be of interest to researchers of hospital error interested in questions of research technique.

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Human factors in pediatric anesthesia incidents

Abstract: In our institution anesthetic human factors occur in 42.5% of in-theater incidents in pediatric anesthesia. Knowledge of these is necessary so that changes can be made in practice both by individuals and departments of anesthesia, to make anesthesia as safe as possible.

Cited by 71 publications

References 18 publications

Audits and critical incident reporting in paediatric anaesthesia: lessons from 75,331 anaesthetic

Audits and critical incident reporting in paediatric anaesthesia: lessons from 75,331 anaesthetic

Implementation of safety checklists in medicine: not as simple as it sounds

Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance?

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