What is the clinical evidence from this study?

Study design: Observational. Population: Preventable anesthesia mishaps (n=47). Primary outcome: Characteristics of human error and equipment failure in anesthetic practice.

What question did this study set out to answer?

To identify and characterize recurring patterns of preventable human errors and equipment failures occurring during clinical anesthesia.

December 1, 1978AnesthesiologyOpen Access

Preventable Anesthesia Mishaps

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Key result

A retrospective analysis of 359 preventable anesthesia incidents found that 82% involved human error, while overt equipment failures accounted for only 14%.

Population

47 staff and resident anesthesiologists at one urban teaching institution describing 359 preventable incidents

Design

Cross-sectional

Authors

JCJeffrey B. CooperHarvard University RNRonald S. NewbowerBoston University CLCharlene D. LongHarvard University

Discussion

Member takes

Implication

Supports emphasis on human factors in anesthesia; leaves open optimal prevention strategies pending prospective data.

Key Points

To identify and characterize recurring patterns of preventable human errors and equipment failures occurring during clinical anesthesia.
Conducted 47 retrospective interviews with staff and resident anesthesiologists at an urban teaching institution using a modified critical-incident analysis technique.
Analyzed descriptions of 359 preventable incidents across 23 detail categories using computer-aided trend analysis.
Human error accounted for 82% of preventable incidents, with breathing-circuit disconnections, inadvertent gas flow alterations, and drug-syringe errors occurring most frequently.
Overt equipment failures comprised 14% of incidents, though flawed equipment design, unfamiliarity, haste, distraction, and poor communication substantially contributed to errors.

Study Design

Type

Observational (n=47)

Multicenter

Structured PICO

Population

47 staff and resident anesthesiologists at one urban teaching institution describing 359 preventable incidents

Outcome

Characteristics of human error and equipment failure in anesthetic practicesafety

Human error accounts for the vast majority of preventable anesthesia mishaps, highlighting the need for improved equipment design, training, and communication.

Cite This Study

Cooper et al. (1978) conducted an observational in Preventable anesthesia mishaps (n=47). A retrospective analysis of 359 preventable anesthesia incidents found that 82% involved human error, while overt equipment failures accounted for only 14%.

synapsesocial.com/papers/6a154caba2f71238514e47e7 https://doi.org/10.1097/00000542-197812000-00004

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December 1, 1978AnesthesiologyOpen Access

Preventable Anesthesia Mishaps

View Full Paper

Ask AI

Bookmark

Key result

A retrospective analysis of 359 preventable anesthesia incidents found that 82% involved human error, while overt equipment failures accounted for only 14%.

Population

47 staff and resident anesthesiologists at one urban teaching institution describing 359 preventable incidents

Design

Cross-sectional

Authors

JCJeffrey B. CooperHarvard University RNRonald S. NewbowerBoston University CLCharlene D. LongHarvard University

Discussion

Member takes

Implication

Supports emphasis on human factors in anesthesia; leaves open optimal prevention strategies pending prospective data.

Key Points

To identify and characterize recurring patterns of preventable human errors and equipment failures occurring during clinical anesthesia.
Conducted 47 retrospective interviews with staff and resident anesthesiologists at an urban teaching institution using a modified critical-incident analysis technique.
Analyzed descriptions of 359 preventable incidents across 23 detail categories using computer-aided trend analysis.
Human error accounted for 82% of preventable incidents, with breathing-circuit disconnections, inadvertent gas flow alterations, and drug-syringe errors occurring most frequently.
Overt equipment failures comprised 14% of incidents, though flawed equipment design, unfamiliarity, haste, distraction, and poor communication substantially contributed to errors.

Study Design

Type

Observational (n=47)

Multicenter

Structured PICO

Population

47 staff and resident anesthesiologists at one urban teaching institution describing 359 preventable incidents

Outcome

Characteristics of human error and equipment failure in anesthetic practicesafety

Human error accounts for the vast majority of preventable anesthesia mishaps, highlighting the need for improved equipment design, training, and communication.

Cite This Study

synapsesocial.com/papers/6a154caba2f71238514e47e7 https://doi.org/10.1097/00000542-197812000-00004

Also Consider

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