Abstract
Understanding the various causes behind medical errors is key to improving patient safety. Reporting and analysis of near-miss events and adverse outcomes yields valuable information about system failures behind the incident and may lead to system redesign in order to prevent reoccurrence. The root cause analysis is a systematic approach to analyze adverse events and critical incidents. The root cause analysis analyzes what happened, how it happened, why it happened, and what can be done to prevent it from happening again. Through these steps, systems failures resulting in active and latent errors, such as human performance factors, organizational factors, and team communication issues are identified and systems are redesigned. This chapter illustrates the application of the root cause analysis using cases from the Closed Claims Database, including facial burns from an electrocautery-induced operating room fire and death from failed extubation of a difficult airway.
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Abbreviations
- AIRS:
-
Anesthesia incident reporting system
- ASA:
-
American Society of Anesthesiologists
- CIR:
-
Critical incident reporting
- L/min:
-
Liters per minute
- MAC:
-
Monitored anesthesia care
- NACOR:
-
National Anesthesia Clinical Outcomes Registry
- O2 :
-
Oxygen
- OR:
-
Operating room
- OSA:
-
Obstructive sleep apnea
- PACU:
-
Postanesthesia care unit
- RCA:
-
Root cause analysis
- TOF:
-
Train of four
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Metzner, J., Posner, K.L., Domino, K.B. (2014). Learning from Incident Reporting and Closed Claims Analyses. In: Frost, E. (eds) Comprehensive Guide to Education in Anesthesia. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-8954-2_3
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DOI: https://doi.org/10.1007/978-1-4614-8954-2_3
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