Preventable anesthesia mishaps: a study of human factors*

Keywords

Medicine, Human error, Medical emergency, Incident report, Distraction

References

• Death in the operating roomAntonio Boba — 1965
• The experimenter's dilemma.John Jung — 1971
• A study of the deaths associated with anesthesia and surgery: based on a study of 599, 548 anesthesias in ten institutions 1948-1952, inclusive.Henry K. Beecher, Donald P. Todd — 1954
• 'There, but for the grace of God...'.W.D. Wylie — 1975
• Physician Performance and Its Effects on Patients: A Classification Based on Reports by Internists, Surgeons, Pediatricians, and ObstetriciansPaul J. Sanazaro, John Williamson — 1970
• The role of anesthesia in surgical mortality.Robert D. Dripps — 1961
• DEATHS ASSOCIATED WITH ANAESTHESIA.Barry Clifton, W. I. T. Hotten — 1963
• UNEXPECTED CARDIAC ARREST DURING ANESTHESIA AND SURGERYGordon Taylor, C. Philip Larson, RAMUNE PRESTWICH — 1977
• A critical incident study of hospital medication errors.Miriam Aronstein Safren, A. Chapanis — 1960
• Theories of vigilance.Judith P. Frankmann, Jack A. Adams — 1962
• A New Anesthesia Delivery SystemJeffrey B. Cooper, Ronald S. Newbower, Jeffrey W. Moore — 1978
• Equipment design and "human" limitations.LUDWIG L. BLUM — 1971
• Vigilance: A Review and Re-evaluationHarry J. Jerison, Ronald M. Pickett — 1963
• The critical incident technique.John C. Flanagan — 1954
• Unexpected cardiac arrest during anesthesia and surgery. An environmental study.Gordon Taylor — 1976
• DEATHS ASSOCIATED WITH ANESTHESIA *1952
• Anesthesia mortality.O C Phillips, Leonard S. Capizzi — 1974
• Deaths associated with anesthesia: a report on 1000 cases.G. Edwards, H. Morton, E. Pask — 1956

Cited by

• Review of Critical Incidents in a University Department of AnaesthesiaTomoyuki Saito, Zee Wan Wong, Kyu Kyu Thinn — 2015
• Anesthesia crisis resource management: real-life simulation training in operating room crises.健太郎 若松, ゆり子 永瀬, 健一 岩下 — 1995
• Generation of Dynamically Configured Check Lists for Intra-Operative Problems: Using a Set Covering AlgorithmT Sawa, Lucila Ohno‐Machado — 2002
• Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006–2008 *将之 吉田 — 2011
• An Alarm for Monitoring CPAPB. Carter, D. Clare, M. Hochmann — 1993
• The fatigued anesthesiologist: A threat to patient safety?Mário Valduga Reckziegel, Henrique de Fries, Lisiane Pires de Souza — 2013
• CRNA performance using a handheld, computerized, decision-making aid during critical events in a simulated environment: a methodologic inquiry.Vicki C. Coopmans, Chuck Biddle — 2008
• Sleep disorders among French anaesthesiologists and intensivists working in public hospitals: A self-reported electronic survey赵健, 谢端, 范训礼 — 2015
• An assessment of the effectiveness of the revised FDA checklist.R. E. W. Manley, James D. Cuddeford — 1996
• An evaluation of the effectiveness of a hospital clinical adverse event prevention programmeSipho Kabane — 2013
• A Proposed Method for the Measurement of Anesthetist Care VariabilityPaul H. King, Don Pierce, Mike Higgins — 2004
• Assessment of medical equipment in the maternity unit at a district hospital of the greater Tubatse sub-districtMakeku Stella Phala — 2014
• Identifying and Reducing Errors in the Operating TheatreKen Catchpole, Professor Marc de Leval — 2005
• Evaluation of basic perfusion techniques, ECCSIM-Lite simulator.Asako Tokumine, Shinji Ninomiya, Megumi Tokaji — 2010
• A Three-Decade Perspective on Anesthesia SafetyWilliam L. Lanier — 2006
• Accidents do not happen--they are caused.Peter Sykes — 1992
• Les modalités du contrôle cognitif en situation dynamique : anticipation et gestion des dérives. Le cas de l'anesthésieValérie Neyns — 2011
• Production pressure, medical errors, and the pre-anesthesia checkout.Samuel DeMaria, Steven M. Neustein — 2010
• Preliminary analysis of perfusionists' strategies for managing routine and failure mode scenarios in cardiopulmonary bypass.Gerald Power, Anne Miller — 2007
• Research Paper: The Evaluation of a Pulmonary Display to Detect Adverse Respiratory Events Using High Resolution Human SimulatorS. Blake Wachter, Ken B. Johnson, Robert Albert — 2006

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