Reported significant observations during anaesthesia: a prospective analysis over an 18-month period.
We describe a prospective analysis, in one hospital, of reported significant observations involving unsafe practices and working conditions during anaesthesia. Of the 549 significant observations reported voluntarily during a period of 18 months, 82% involved occurrences which were considered preventable and 27% could have been fatal if they had not been recognized and corrected. Ninety-three percent of incidents did not lead to a negative outcome. Human error was responsible for 411 (75%) reports. Lack of vigilance and failure to check were the most frequently reported factors associated with human error. Significant observations involving errors in drugs administration were the most frequent. Forty-five percent of all reported significant observations were made during maintenance of anaesthesia.
Chopra
V
V
Department of Anaesthesiology, University Hospital Leiden, The Netherlands.
Bovill
J G
JG
Spierdijk
J
J
Koornneef
F
F
D000758:Anesthesia / Q000009:adverse effects*; D000776:Anesthesiology / Q000592:standards*; D006801:Humans; D008508:Medication Errors; D009426:Netherlands; D011446:Prospective Studies; D011787:Quality of Health Care; D012307:Risk Factors; D012449:Safety; D013997:Time Factors