title: Human factors analysis of a near-miss event: oxygen supply failure during cardiopulmonary bypass.
authors.affiliation: Departments of Anesthesiology, Cardiac Surgery and Perfusion, Virginia Commonwealth University Medical Center, Richmond, Virginia; Flawless Operative Cardiovascular Unified Systems (FOCUS) Initiative Team member. Electronic address: BDSpiess@HSC.VCU.EDU.
authors.forename: Bruce D
authors.initials: BD
authors.lastname: Spiess
authors.affiliation: Department of Anesthesiology, National Naval Medical Center, Bethesda, Maryland.
authors.forename: John
authors.initials: J
authors.lastname: Rotruck
authors.affiliation: Departments of Anesthesiology, Cardiac Surgery and Perfusion, Virginia Commonwealth University Medical Center, Richmond, Virginia.
authors.forename: Harry
authors.initials: H
authors.lastname: McCarthy
authors.affiliation: Departments of Anesthesiology, Cardiac Surgery and Perfusion, Virginia Commonwealth University Medical Center, Richmond, Virginia.
authors.forename: Olga
authors.initials: O
authors.lastname: Suarez-Wincosci
authors.affiliation: Departments of Anesthesiology, Cardiac Surgery and Perfusion, Virginia Commonwealth University Medical Center, Richmond, Virginia.
authors.forename: Vigneshwar
authors.initials: V
authors.lastname: Kasirajan
authors.affiliation: Department of Anesthesiology, The University of Minnesota, Minneapolis, Minnesota; Flawless Operative Cardiovascular Unified Systems (FOCUS) Initiative Team member.
authors.forename: Joyce
authors.initials: J
authors.lastname: Wahr
authors.affiliation: Department of Human Factors and Systems, Embrey-Riddle Aeronautical University, Daytona, Florida.
authors.forename: Scott
authors.initials: S
authors.lastname: Shappell
mesh_terms: D001784:Blood Gas Analysis / Q000379:methods / Q000592:standards*; D002315:Cardiopulmonary Bypass / Q000009:adverse effects / Q000295:instrumentation*; D004868:Equipment Failure; D005163:Factor Analysis, Statistical; D006801:Humans; D008297:Male; D008875:Middle Aged; D010092:Oximetry / Q000379:methods / Q000592:standards
keywords: cardiopulmonary bypass; cerebral oximetry; human factors; hypoxemia; near miss; oxygen failure; patient safety