Abstract
Over the past decade, anaesthetists and human factors specialists have worked together to find ways of minimising the human contribution to anaesthetic mishaps. As in the functionally similar fields of aviation, process control and military operations, it is found that errors are not confined to those at the "sharp end". In common with other complex and well defended technologies, anaesthetic accidents usually result from the often unforeseeable combination of human and organisational failures in the presence of some weakness or gap in the system's many barriers and safeguards. Psychological factors such as inattention, distraction and forgetfulness are the last and often the least manageable aspects of the accident sequence. Whereas individual unsafe acts are hard to predict and control, the organisational and contextual factors that give rise to them are present before the occurrence of an incident or accident. As such, they are prime candidates for treatment. Errors at the sharp end are symptomatic of both human fallibility and underlying organisational failings. Fallibility is here to stay. Organisational and local problems, in contrast, are both diagnosable and manageable.
Full Text
The Full Text of this article is available as a PDF (95.6 KB).
Selected References
These references are in PubMed. This may not be the complete list of references from this article.
- Caplan R. A., Posner K. L., Cheney F. W. Effect of outcome on physician judgments of appropriateness of care. JAMA. 1991 Apr 17;265(15):1957–1960. [PubMed] [Google Scholar]
- Chopra V., Bovill J. G., Spierdijk J., Koornneef F. Reported significant observations during anaesthesia: a prospective analysis over an 18-month period. Br J Anaesth. 1992 Jan;68(1):13–17. doi: 10.1093/bja/68.1.13. [DOI] [PubMed] [Google Scholar]
- Cooper J. B., Cullen D. J., Nemeskal R., Hoaglin D. C., Gevirtz C. C., Csete M., Venable C. Effects of information feedback and pulse oximetry on the incidence of anesthesia complications. Anesthesiology. 1987 Nov;67(5):686–694. doi: 10.1097/00000542-198711000-00012. [DOI] [PubMed] [Google Scholar]
- Currie M., Mackay P., Morgan C., Runciman W. B., Russell W. J., Sellen A., Webb R. K., Williamson J. A. The Australian Incident Monitoring Study. The "wrong drug" problem in anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993 Oct;21(5):596–601. doi: 10.1177/0310057X9302100517. [DOI] [PubMed] [Google Scholar]
- Eagle C. J., Davies J. M., Reason J. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Can J Anaesth. 1992 Feb;39(2):118–122. doi: 10.1007/BF03008640. [DOI] [PubMed] [Google Scholar]
- Mayor A. H., Eaton J. M. Anaesthetic machine checking practices. A survey. Anaesthesia. 1992 Oct;47(10):866–868. doi: 10.1111/j.1365-2044.1992.tb03151.x. [DOI] [PubMed] [Google Scholar]
- Runciman W. B., Webb R. K., Lee R., Holland R. The Australian Incident Monitoring Study. System failure: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993 Oct;21(5):684–695. doi: 10.1177/0310057X9302100535. [DOI] [PubMed] [Google Scholar]
- Weir P. M., Wilson M. E. Are you getting the message? A look at the communication between the Department of Health, manufacturers and anaesthetists. Anaesthesia. 1991 Oct;46(10):845–848. doi: 10.1111/j.1365-2044.1991.tb09598.x. [DOI] [PubMed] [Google Scholar]
- Williamson J. A., Webb R. K., Sellen A., Runciman W. B., Van der Walt J. H. The Australian Incident Monitoring Study. Human failure: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993 Oct;21(5):678–683. doi: 10.1177/0310057X9302100534. [DOI] [PubMed] [Google Scholar]