Root cause analysis of blunders in anesthesia

Rayan, Ayman A; Hemdan, Sherif Essam; Shetaia, Ayman Mohamed

doi:10.4103/aer.aer_47_19

Cited by 11 publications

(7 citation statements)

References 39 publications

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“…Consensus points to medication errors as the most prevalent, with frequencies ranging from 0.075% to 0.7%. [ 3 ] In India, a study pinpointed the pressure to expedite tasks as a significant contributor to medication errors in the operating room. [ 4 ] Human error emerges as a dominant factor, implicated in over 80% of critical incidents in anaesthesia.…”

Section: Discussionmentioning

confidence: 99%

Perioperative crisis resource management simulation training in anaesthesia

Pai,

Kumar,

Sobana

2024

Indian Journal of Anaesthesia

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Simulation-based education is now recognised to be a valuable tool to impart both technical and non-technical skills to healthcare professionals of all levels. Simulation is an well accepted educational tool for cultivating teamwork skills among residents globally. Simulation-based education encompasses diverse modalities, ranging from task trainers and simulated patients to sophisticated high-fidelity patient simulators. Notably, anaesthesiologists globally were early advocates of integrating simulation into education, particularly to instruct anaesthesia residents about the intricacies of perioperative crisis resource management and collaborative interdisciplinary teamwork. Given the inherent high-risk nature of anaesthesia, where effective teamwork is pivotal to averting adverse patient outcomes, and also to improve overall outcome of the patient, simulation training becomes imperative. This narrative review delves into the contemporary landscape of simulation training in perioperative anaesthesia management, examining the pedagogical approaches, simulators, techniques and technologies employed to facilitate this training.

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Section: Discussionmentioning

confidence: 99%

Perioperative crisis resource management simulation training in anaesthesia

Pai,

Kumar,

Sobana

2024

Indian Journal of Anaesthesia

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“…[40] Misidentifying syringes because of poor labeling is common in the literature. [41,42] In addition to poor labeling, our respondents identified poor communication to have contributed to 48% of errors. Leonard et al [43] analyzed 2400 adverse events and found that ineffective communication contributed to 70% of them.…”

Section: Factors Causing Medication Errorsmentioning

confidence: 92%

Assessment of Medication Errors Among Anesthesia Clinicians in Saudi Arabia: A Cross-Sectional Survey Study

Aldossary¹,

Almandeel²,

Alzahrani³

et al. 2021

Global Journal on Quality and Safety in Healthcare

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Introduction Anesthetic drugs are prepared and administrated without referral to the pharmacy or other medical departments. We aimed to assess the occurrence of anesthetic drug errors in Saudi Arabia. We also determined the contributing factors, reporting strategies, and clinicians' opinions of the preventive measures. Methods We conducted a cross-sectional web-based survey study using a validated tool. A total of 300 anesthesia clinicians completed the survey (146 anesthesiologists and 154 anesthesia technology specialists). We measured descriptive statistics to describe the demographic characteristics and performed inferential statistics to examine associations and differences. Results Sixty-nine percent of respondents had experienced an anesthetic drug error at least once in their career. The two primary factors that caused drug errors were haste (60.3%) and heavy workload (60.3%). On syringe labeling, 56.3% withdrew the drug then labeled the syringe, and 43.7% labeled the syringe then withdrew the drug. The chi-square test revealed that clinicians who labeled the syringe first then withdrew the drug made errors more frequently (p = 0.036). The test also showed that clinicians with less experience had committed more errors (p = 0.015). On reporting drug errors, 77.7% of respondents identified the fear of medicolegal issues as the most common barrier to reporting errors. Respondents believed that double-checking the medication and color-coded syringe labels were the most effective strategies to reduce errors (82% and 64%, respectively). The Mann-Whiney U test revealed significant differences between the two specialties about their opinions of the preventive measures. Conclusions There was a high occurrence rate of anesthetic drug errors in Saudi Arabia. Policymakers need to unify the syringe-labeling practice, and future research needs to focus on what makes a nonpunitive culture to encourage reporting errors.

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“…RCA on the most frequent errors occurring in anesthesia cases of complex procedures were found to be fine skills of the experts and knowledge deficiencies, poor time management, lack of communication, unfamiliarity with the equipment, and drug-related errors [27]. RCA has also been used to identify the causes of myocardial infarction deaths [28].…”

Section: Quality Monitoring and Turnaround Timementioning

confidence: 99%

Root Cause Analysis: Unraveling Common Laboratory Challenges

Srinivasaragavan,

Ramalingam,

Ramani

2024

Cureus

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Diverse errors occur in a pathology laboratory and manual mistakes are the most common. There are various advancements to replace manual procedures with digitized automation techniques. Guidelines and protocols are available to run a standard pathology laboratory. But, even with such attempts to reinforce and strengthen the protocols, the complete elimination of errors is yet not possible. Root cause analysis (RCA) is the best way forward to develop an error-free laboratory, In this review, the importance of RCA, common errors taking place in laboratories, methods to carry out RCA, and its effectiveness are discussed in detail.The review also highlights the potential of RCA to provide long-term quality improvement and efficient laboratory management.

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Root cause analysis of blunders in anesthesia

Cited by 11 publications

References 39 publications

Perioperative crisis resource management simulation training in anaesthesia

Perioperative crisis resource management simulation training in anaesthesia

Assessment of Medication Errors Among Anesthesia Clinicians in Saudi Arabia: A Cross-Sectional Survey Study

Root Cause Analysis: Unraveling Common Laboratory Challenges

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