Anaesthesia and intensive care
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice.
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). ⋯ 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.
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. System failure: an analysis of 2000 incident reports.
Although 70-80% of problems have some component of human error, its overall contribution to many problems may be small; studies of complex systems have revealed that up to 85% are primarily due to deficiencies in the lay-out and processes of the system. The anaesthetist has to operate in a complex system; many problems originate from deficiencies in this system. Information of relevance to system failure was extracted from the first 2000 incidents reported to the Australian Incident Monitoring Study (AIMS). ⋯ Level III involves interaction between AIMS and the major professional bodies and level IV interaction between AIMS, these bodies and a variety of national and international agencies. Over 100 topics were identified from the AIMS data for consideration at one or more of these levels. AIMS has the potential not only to play a vital practical role in the continued enhancement of the quality of anaesthetic practice, but also to provide a valuable resource for research at the increasingly important interface between human behaviour and complex systems.
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. Which monitor? An analysis of 2000 incident reports.
The role of monitors in patients undergoing general anaesthesia was studied by analysing the first 2000 incidents reported to the Australian Incident Monitoring Study; 1256 (63%) were considered applicable to this study. In 52% of these a monitor detected the incident first; oximetry (27%) and capnography (24%) detected over half of the monitor detected incidents, the electrocardiograph 19%, blood pressure monitors 12%, a low pressure (circuit) alarm 8%, and the oxygen analyser 4%. Of the other monitors used, 5 first detected 1-2% of incidents, and the remaining 8 less than 0.5% each. ⋯ Other monitors, including the ECG, each increase the yield by by less than 0.5%. The international monitoring recommendations and those of the Australian and New Zealand College of Anaesthetists are thoroughly vindicated by the patterns revealed in this study. The priority sequence of monitor acquisition for those with limited resources should be stethoscope, sphygmomanometer, oxygen analyser if nitrous oxide is to be used, pulse oximeter, capnograph, high pressure alarm, and, if patients are to be mechanically ventilated, a low pressure alarm (or spirometer with alarm); an ECG, a defibrillator, a spirometer and a thermometer should be available.
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. Problems with ventilation: an analysis of 2000 incident reports.
A review of the first 2000 incidents reported to the Australian Incident Monitoring Study found 317 incidents which involved problems with ventilation. The major portion (47%) were disconnections; 61% of these were detected by a monitor. Monitor detection was by a low circuit pressure alarm in 37% but this alarm failed to warn of non-ventilation in 12 incidents (in 6 because it was not switched "on" and in 6 because of a failure to detect the disconnection). ⋯ The frequency of a complete failure to check an anaesthetic machine was greater when an induction room was involved than when only the operating theatre was the site of the incident. These incidents suggest that meticulous checking and monitoring for failure of ventilation, preferably using at least two separate, self-activating systems is highly desirable. The Australian and New Zealand College of Anaesthetists' policy on low circuit pressure alarms, oximetry and capnography is vindicated by these reports.
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. The capnograph: applications and limitations--an analysis of 2000 incident reports.
The first 2000 incidents reported to the Australian Incident Monitoring Study were analysed with respect to the role of the capnograph. One hundred and fifty-seven (8%) were first detected by a capnograph and there were a further 18 (1%) in which capnography was contributory. Of the 1256 incidents which occurred in association with general anaesthesia 48% were "human detected" and 52% "monitor detected". ⋯ There were 20 reports of "failure", over two-thirds of which would not have occurred with appropriate checking and calibration. Seven were due to gas sampling problems and 6 to apnoea alarm failure. Two circuit leaks and 2 faulty unidirectional valves were not detected; on 3 occasions problems occurred due to power failure, calibration problems, or misinterpretation of an alarm.(ABSTRACT TRUNCATED AT 250 WORDS)