Commentary

Abstract

A modified critical-incident analysis technique was used in a retrospective examination of the characteristics of human error and equipment failure in anesthetic practice. The objective was to uncover patterns of frequently occurring incidents that are in need of careful prospective investigation. Forty seven interviews were conducted with staff and resident anesthesiologists at one urban teaching institution, and descriptions of 359 preventable incidents were obtained. Twenty three categories of details from these descriptions were subjected to computer-aided analysis for trends and patterns. Most of the preventable incidents involved human error (82%), with breathing-circuit disconnections, inadvertent changes in gas flow, and drug syringe errors being frequent problems. Overt equipment failures constituted only 14% of the total number of preventable incidents, but equipment design was indictable in many categories of human error, as were inadequate experience and insufficient familiarity with equipment or with the specific surgical procedure. Other factors frequently associated with incidents were inadequate communication among personnel, haste or lack of precaution, and distraction. Results from multi-hospital studies based on the methodology developed could be used for more objective determination of priorities and planning of specific investments for decreasing the risk associated with anesthesia.

Racelighting in Utah education: counterstories across contexts

“…the narratives that People of Color are incompetent, unqualified or undesirable) (Wood and Harris, 2021b). This interpersonal manipulation can happen in various ways, including denying racism when People of Color point out their racial mistreatment, undervaluing activities or behaviors that are important to People of Color, identifying those activities or behaviors as failings, and fixating on mistakes or failures while not acknowledging successes (Wood and Harris, 2021c), as well as through various According to Wood and Harris (2021b), racelighting is an “outgrowth” of microaggressions the pervasive, everyday attacks and/or dismissals of People of Color (Pierce, 1970; Sue and Constantine, 2007). Microaggressions are often a tool through which People of Color are manipulated into questioning their own racialized experience (p. 39).…”