Errors, Incidents and Accidents in Anaesthetic Practice

Abstract

Human error is a pervasive and normal part of everyday life and is of interest to the anaesthetist because errors may lead to accidents. Definitions of, and the relationships between, errors, incidents and accidents are provided as the basis to this introduction to the psychology of human error in the context of the work of the anaesthetist. Examples are drawn from the Australian Incident Monitoring Study (AIMS). An argument is put forward for the use of contemporaneous incident reporting (eliciting relevant contextual information as well as details of use to cognitive psychologists), rather than the use of accident investigation after the event (with the inherent problems of scant information, altered perception and outcome bias). A classification of errors is provided. ';4ctive" errors may be classified into knowledge-based, rule-based, skill-based and technical errors. Different strategies are required for the prevention of each type and it may now be useful to place more emphasis in anaesthetic practice on categories to which little attention has been directed in the past. "Latent" errors make an enormous contribution to problems in anaesthesia and several categories are discussed (e.g. environment, physiological state, equipment, work practices, personnel training, social and cultural factors). An approach is provided for the prevention and management of errors, incidents and accidents which allows clinical problems to be categorized, the relative importance of various contributing factors to be established, and appropriate preventative strategies to be devised and implemented on the basis of priorities determined from the AIMS data. Accidents cannot be abolished; however, an understanding of the factors underlying them can lead to the rational direction of resources and effort to prevent them and minimise their effects.

Clinical safety of England's national programme for IT: A retrospective analysis of all reported safety events 2005 to 2011

“…Problems involving human factors were four times as likely to result in harm to patients than technical problems. This is consistent with other research into human error in aviation where typically 70-80% of serious events in complex systems involve use errors [26,27]. At present there are no requirements for safe use of health IT and our findings reinforce a critical need for policies to guide safe use [28].…”

“…The limitations of our findings are those inherent to all event reports, notably that reports only provide a "snapshot" of events [36]. However large collections can be used to identify characteristic profiles, allowing clusters of like events to be aggregated and analysed [27]. The events examined in this study were managed by a dedicated IT safety team that actively sought to address problems.…”

The policy and the practice: early-career doctors and nurses as leaders and followers in the delivery of health care

“…Discussions of adverse events in the healthcare quality and safety patient care literature suggest that the majority of causes of error are in deficiencies in non-technical skills, including communication failure, poor teamworking, poor leadership or poor decision-making (Gawande et al 2003;Mallory et al 2003;Runciman et al 1993). Conversely, the smooth performance of teams has been linked to improved patient outcomes (Grumbach and Bodenheimer 2004).…”

Safety-II and resilience

“…The medical literature counts numerous articles on failures, error rates, incident reporting, root-cause analysis and so on. The Swiss 'Critical Incident Reporting System' (CIRS), the first electronic incident reporting system in anesthesiology on the Internet has been published almost 20 years ago after the leading publications from Australia [26,27].…”