Human error, particularly failure to perform normal checks, is the most frequent cause of anaesthetic misadventures, highlighting the need for departmental discussion and teaching.
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May warrant enhanced focus on pre-anaesthetic checks; cross-sectional data leaves open efficacy of targeted interventions.
Reports of anaesthetic misadventures were regularly collected in the Anaesthetic Department of a district general hospital, to identify recurring problems. Eighty-one misadventures, none of which had serious outcome, were reported during a 6-month period, in which 8312 anaesthetics were administered. Human error was more frequently responsible than equipment failure, and failure to perform a normal check was the factor most frequently associated. Local hazard warnings were circulated when necessary to members of the Department, and the reports formed the basis of departmental discussion and teaching.
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Craig et al. (1981) studied this question.
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