QRB. Quality review bulletin
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Human error and mechanical failure in anesthesia frequently cause incidents which, if not detected and corrected in time, could lead to increased patient morbidity or mortality. A study was conducted to analyze the human and technical factors that contribute to such incidents. The data thus obtained proved useful in reducing preventable anesthesia mishaps in specific institutions and generated recommendations for improving anesthesia practice in general.
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Because small hospitals tend to have few members on their anesthesia services, perform less complicated and less extensive surgical procedures, use relatively straightforward anesthesia regimes, and have low anesthesia complication rates, foci for review may be difficult to identify. A review of intraoperative and postoperative mortality can be a productive approach, however. The authors provide criteria to help small hospitals identify problem areas in the delivery of anesthesia care through mortality review.