Mortality associated with anaesthesia. A case review study.
The review is based on an analysis of anonymous case record material at the Medical Protection Society's London Office for the 5-year period 1982-1986, in which death was associated with anaesthetic procedures. A total of 25 cases were analysed. The principal events which resulted in death were failed intubation, drug-related problems and problems with equipment. The principal contributory factors were inadequate supervision, inadequate pre-operative assessment and failure of communication. The present review suggests that supervision and training of junior staff, decision-making by senior staff and patterns of communication both within and between specialties are areas which should be selected for further research.
Gannon
K
K
Royal London Hospital Medical College, School of Occupational Therapy.
D000328:Adult; D000758:Anesthesia / Q000401:mortality*; D000776:Anesthesiology / Q000193:education; D002423:Cause of Death; D003142:Communication; D004868:Equipment Failure; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects; D008297:Male; D008318:Malpractice; D008485:Medical Audit