PREVENTABLE ANESTHESIA MISHAPS - STUDY OF HUMAN-FACTORS
PREVENTABLE ANESTHESIA MISHAPS - STUDY OF HUMAN-FACTORS
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DOI：
10.1097/00000542-197812000-00004
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发表时间：
1978-01-01
期刊：
影响因子：
8.8
通讯作者：
NEWBOWER, RS
中科院分区：
文献类型：
--
作者：
COOPER, JB;MCPEEK, B;NEWBOWER, RS
一种改良的关键事件分析技术被用于回顾性研究麻醉实践中的人为错误和设备故障的特点。其目的是揭示经常发生的事件的模式，需要进行仔细的前瞻性调查。访谈（47）进行了工作人员和住院麻醉师在一个城市的教学机构，并获得了359个可预防的事件的描述。对这些描述中的23类细节进行了计算机辅助分析，以确定趋势和模式。大多数可预防的事件涉及人为错误（82%），呼吸回路断开，气流的无意变化和药物注射器错误是常见的问题。公开的设备故障仅占所有可预防事件的14%，但设备设计在许多类别的人为错误中是可起诉的，因为经验不足，对设备或特定外科手术的熟悉程度不足。其他经常与事件有关的因素是人员之间沟通不足、仓促行事或缺乏预防措施以及注意力分散。基于所开发方法的多医院研究结果可用于更客观地确定优先级和规划具体投资，以降低麻醉相关风险。
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. Interviews (47) were conducted with staff and resident anesthesiologists at 1 urban teaching institution, and descriptions of 359 preventable incidents were obtained. Categories (23) of details from these descriptions were subjected to computer-aided analysis for trends and patterns. Most 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 all 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.