Key result
Root cause analysis and fish bone techniques were used to investigate a critical incident of equipment failure during difficult airway management, leading to recommendations for risk reduction.
Case Report
Highlights the importance of risk management, human factors, and equipment checking in perioperative difficult airway management to avoid critical incidents.
This work is set in the context of perioperative practice in difficult airway management. It integrates a root cause analysis and fish bone technique to investigate a critical incident in temporary yet crucial equipment failure. Risk management and incident reporting is analysed alongside human factors in the operating theatre environment. Finally, recommendations for risk reduction, vigilance and checking vital airway equipment are made in anaesthetic practice.
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Potts et al. (2017) conducted a case report in Difficult airway management in perioperative practice. Root cause analysis and fish bone technique was evaluated. Root cause analysis and fish bone techniques were used to investigate a critical incident of equipment failure during difficult airway management, leading to recommendations for risk reduction.
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