“Equipment problems” is probably a misnomer; the ASA Closed Claims Project review of 72 claims involving gas delivery systems found that equipment misuse was three times more commonthanequip-ment malfunction. The majority (76%) of adverse
outcomes associated with gas delivery problems were either death or permanent neurological damage.
Errors in drug administration also typically involve human error. It has been suggested that as many as 20% of the drug doses given to hospitalized patients are incorrect. Errors in drug administration account for 4% of cases in the ASA Closed Claims Project, which found that errors resulting in claims were most frequently due to either incorrect dosage or unintentional administration of the wrong drug (syringe swap). In the latter category, accidental administration of epinephrine proved particularly dangerous.
Another type of human error occurs when the most critical problem is ignored because attention is inappropriately focused on a less important problem or an incorrect solution (fixation error). Serious anesthetic mishaps are often associated with distrac-tions and other factors (Table 54–3). The impact of most equipment failures is decreased or avoided when the problem is identified during a routine preoperative checkout performed by adequatelytrained personnel. Many anesthetic fatalities occur only after a series of coincidental circumstances, misjudgments, and technical errors coincide (mishap chain).
Strategies to reduce the incidence of serious anes-thetic complications include better monitoring and anesthetic techniques, improved education, more comprehensive protocols and standards of prac-tice, and active risk management programs. Better monitoring and anesthetic techniques imply more comprehensive monitoring and ongoing patient assessments and better designed anesthesia equip-ment and workspaces. The fact that most accidents occur during the maintenance phase of anesthesia— rather than during induction or emergence—implies a failure of vigilance.
Inspection, palpation, percussion, and ausculta-tion of the patient provide important information. Instruments should supplement (but never replace) the anesthesiologist’s own senses. To minimize errors in drug administration, drug syringes and ampoules in the workspace should be restricted to those needed for the current specific case. Drugs should be consistently diluted to the same concen-tration in the same way for each use, and they should be clearly labeled. Computer systems for scanning bar-coded drug labels are available that may help to reduce medication errors. The conduct of all anes-thetics should follow a predictable pattern by which the anesthetist actively surveys the monitors, the surgical field, and the patient on a recurrent basis. In particular, patient positioning should be frequently reassessed to avoid the possibility of compression or stretch injuries. When surgical necessity requires patients to be placed in positions where harm may occur or when hemodynamic manipulations (eg, deliberate hypotension) are requested or required, the anesthesiologist should note on the record the surgical request and remind the surgeon of any potential risks to the patient.
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