Key result
Among 36 anesthesia-specific adverse events in VHA hospitals, medication errors were the most common (28%), and 42% of all events resulted in major or catastrophic outcomes.
Population
36 root cause analysis reports of adverse events specific to anesthesia care from Veterans Health…
Authors
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Alerts to severe anesthesia events in VHA; hypothesis-generating for medication safety protocols, should not yet change practice.
Observational (n=36)
Yes
Medication errors remain the most common anesthesia-related adverse event in the VHA, highlighting the need for systemwide human factors engineering approaches.
Neily et al. (2017) conducted an observational in Anesthesia adverse events (n=36). Anesthesia care was evaluated on Types and severity of anesthesia adverse events. Among 36 anesthesia-specific adverse events in VHA hospitals, medication errors were the most common (28%), and 42% of all events resulted in major or catastrophic outcomes.
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