Patient risk in anesthesia: Probabilistic risk analysis and management improvements

Paté‐Cornell, Elisabeth; Murphy, D M; Lakats, Linda M.; Gaba, David M.

doi:10.1007/bf02187030

Cited by 19 publications

(9 citation statements)

References 16 publications

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“…Given the dramatic impact that medical error has on both patient well-being and health-care costs coupled with American society's ever-growing litigious nature, risk management has become an invaluable tool for medical leadership. As observed with the research of Elisabeth Paté-Cornell et al, 27 patient injury during surgery represents a system failure. The impact of the failure ranges from injury to death and includes all associated costs, both monetary and emotional.…”

Section: Quality Control and Risk Managementmentioning

confidence: 88%

Physician Leadership: The Competencies of Change

Chaudry

Jain

McKenzie

et al. 2008

Journal of Surgical Education

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Section: Quality Control and Risk Managementmentioning

confidence: 88%

Physician Leadership: The Competencies of Change

Chaudry

Jain

McKenzie

et al. 2008

Journal of Surgical Education

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“…A more limited literature relates to health care [2] where adapted methods such as Health Care Failure Modes and Effects Analysis [3] have been used to assess risks in high risk systems such as blood transfusion [4]. Other methods, such as socio-technical probabilistic risk analysis [5], are being used in aspects of medication safety or have been used in the study of complex environments such as anaesthesia [6]. …”

Section: Introductionmentioning

confidence: 99%

Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway

Dean

Hutchinson

Escoto

et al. 2007

BMC Health Serv Res

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Background: Care pathways can be complex, often involving multiple care providers and as such are recognised as containing multiple opportunities for error. Prospective hazard analysis methods may be useful for evaluating care provided across primary and secondary care pathway boundaries. These methods take into account the views of users (staff and patients) when determining where potential hazards may lie. The aim of this study is to evaluate the feasibility of prospective hazard analysis methods when assessing quality and safety in care pathways that lie across primary and secondary care boundaries.

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“…She and her colleagues examined data gathered in Australia, spent a few days in an operating room, and concluded that although some of the cases were attributable to technical equipment failure, most were caused by human errors. Those were rooted in problems of alertness and competence, seldom related to substance abuse, but with causes that were very close to home: insufficient monitoring of residents and lack of continuous education . Elisabeth et al .…”

Section: Stanford Research and Learning From World Eventsmentioning

confidence: 99%

“…Those were rooted in problems of alertness and competence, seldom related to substance abuse, but with causes that were very close to home: insufficient monitoring of residents and lack of continuous education. (4) Elisabeth et al then recommended regular recertification of anesthesiologists, closer supervision of residents, and simulation training for practitioners.…”

Section: Anesthesia-related Mortalitymentioning

confidence: 99%