Abstract:
: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). An argument is put forward for the use of contemporaneous incident reporting (eliciting relevant contextual information as well as details of use to cognitive psychologists), rather than the use of accident investigation after the event (with the inherent problems of scant information, altered perception and outcome bias). A classification of errors is provided. "Active" errors may be classified into knowledge-based, rule-based, skill-based and technical errors. 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.
journal_name
Anaesth Intensive Carejournal_title
Anaesthesia and intensive careauthors
Runciman WB,Sellen A,Webb RK,Williamson JA,Currie M,Morgan C,Russell WJdoi
10.1177/0310057X9302100506subject
Has Abstractpub_date
1993-10-01 00:00:00pages
506-19issue
5eissn
0310-057Xissn
1448-0271journal_volume
21pub_type
杂志文章abstract::The air-Q Intubating Laryngeal Airway (ILA) is a newly introduced extraglottic airway device. In this pilot study, we evaluated its use as a routine airway device during positive pressure ventilation. Ease of endotracheal intubation through the device was also assessed. Fifty-nine ASA I and II patients undergoing elec...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X1003800217
更新日期:2010-03-01 00:00:00
abstract::We compared the perioperative profiles of patients undergoing unilateral phaeochromocytoma resection performed by open adrenalectomy with those performed by laparoscopic adrenalectomy. Data was collected prospectively on 24 patients (12 open, 12 laparoscopic). All patients underwent extensive preoperative medical prep...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X0403200210
更新日期:2004-04-01 00:00:00
abstract::The objective of this study was to assess the outcome of Jehovah's Witness (JW) patients admitted to a major Australasian ICU and to review the literature regarding the management of critically ill Jehovah's Witness patients. All Jehovah's Witness patients admitted to the ICU between January 1999 and September 2003 we...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X0403200611
更新日期:2004-12-01 00:00:00
abstract::The effect of hypothermia on the action of d-tubocurarine (d-TC) was studied under carefully controlled experimental conditions. It was found that with computer controlled infusion, 60% less d-TC was required to sustain 75% muscle paralysis in cats, during steady-state, in vivo, when the temperature was changed from 3...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X7900700303
更新日期:1979-08-01 00:00:00
abstract::Continuous peripheral nerve blockade is a common technique in the analgesic management for many procedures. Leakage of local anaesthetic from around the nerve catheter insertion site can increase the chance of catheter dislodgement, risks infective complications, and could divert anaesthetic away from the nerve causin...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章,随机对照试验
doi:10.1177/0310057X1804600507
更新日期:2018-09-01 00:00:00
abstract::We report a case of palatopharyngeal wall perforation during intubation with a GlideScope laryngoscope. The likely mechanism was advancing and rotating the endotracheal tube against a taut palatopharyngeal fold. This was missed during the initial laryngoscopy, because there is a potential blind-spot in the oropharynx ...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章,评审
doi:10.1177/0310057X0803600620
更新日期:2008-11-01 00:00:00
abstract::The Competency-Based Training program in Intensive Care Medicine in Europe identified 12 competency domains. Professionalism was given a prominence equal to technical ability. However, little information pertaining to fellows' views on professionalism is available. A nationwide qualitative study was performed. The mod...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X1103900118
更新日期:2011-01-01 00:00:00
abstract::The theoretical performance of the Hudson Multivent mask is considered. A method is described of determining the flow-weighted mean inspired oxygen concentration produced by the mask. Using this method, it was found that the inspired oxygen concentration was predictable only at the 24% setting using the recommended fl...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X8000800109
更新日期:1980-02-01 00:00:00
abstract::Spontaneous rupture of a hydatid cyst is reported in a 19-year-old cattleman. Mechanical ventilation for respiratory failure and a right lower lobectomy were required for flooding of the airway with hydatid cyst fluid. The postoperative course was complicated by the development of acute respiratory distress syndrome. ...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X9802600614
更新日期:1998-12-01 00:00:00
abstract::Defects in the genes coding for the skeletal muscle ryanodine receptor (RYR1) and alpha 1 subunit of the dihydropyridine receptor (CACNA1S) have been identified as causative for malignant hyperthermia (MH). Sixty-two MH susceptible individuals presenting to the same diagnostic centre had copy deoxyribonucleic acid, de...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X1504300204
更新日期:2015-03-01 00:00:00
abstract::Evidence-based choices of volatile agents can increase health cost efficiencies. In this pharmaco-economic study, we evaluated the trends and costs of volatile agent use in Australian public hospitals. The total number of volatile agent (isoflurane, sevoflurane and desflurane) bottles ordered and inflation-adjusted co...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X1404200506
更新日期:2014-09-01 00:00:00
abstract::Prone positioning to improve oxygenation in acute lung injury was first reported over 20 years ago. Although this and several subsequent studies have shown that prone positioning improved oxygenation in the majority of patients, it has failed to become common practice in intensive care units. This paper reviews the me...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章,评审
doi:10.1177/0310057X9902700213
更新日期:1999-04-01 00:00:00
abstract::Cystic fibrosis is an autosomal recessive disorder which affects one in 2500 live births. It is a multisystem disease and has a variety of presentations. The major clinical features affect the gastrointestinal and respiratory tracts. Severe respiratory disease, diabetes and gastroesophageal reflux are common features ...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X9502300310
更新日期:1995-06-01 00:00:00
abstract::The Finapres (Ohmeda, Madison, U.S.A.) is a non-invasive device which continuously measures the arterial blood pressure in a finger and produces a real-time display of the arterial pressure wave. It consists of a finger cuff with an infra-red transmission plethysmograph, a servo control box and a monitor unit. The dev...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X8901700413
更新日期:1989-11-01 00:00:00
abstract::Patient acceptance is a particularly relevant method of assessing currently employed epidural and intravenous techniques of opioid analgesia after elective caesarean section. We have prospectively studied 71 such patients, randomised postoperatively to receive epidural morphine, intravenous morphine or intravenous pet...
journal_title:Anaesthesia and intensive care
pub_type: 临床试验,杂志文章,随机对照试验
doi:10.1177/0310057X9202000108
更新日期:1992-02-01 00:00:00
abstract::There is no consensus that hyperglycaemia is an independent predictor of morbidity-mortality in children. This retrospective observational study aimed to assess the association between abnormal perioperative glucose levels and adverse outcomes in infants receiving open-heart surgery with cardiopulmonary bypass. The re...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X1204000506
更新日期:2012-09-01 00:00:00
abstract::This prospective double-blinded study compared the analgesic effectiveness and incidence of complications of a compound preparation Painstop (Paedpharm Pty Ltd) containing paracetamol 12 mg, codeine 0.5 mg and promethazine 0.65 mg per 1.0 ml, dosage 1.0 ml/kg, with paracetamol 20 mg/kg. Ninety-five children aged 1 to ...
journal_title:Anaesthesia and intensive care
pub_type: 临床试验,杂志文章,随机对照试验
doi:10.1177/0310057X9702500105
更新日期:1997-02-01 00:00:00
abstract::A survey was conducted to investigate the attitudes of anaesthetists and nurses to anaesthetic pollution. In order that the results could be viewed in context, attitudes to other possible occupational hazards, including radiation exposure and work-related stress, were also investigated. Four hundred (66%) completed qu...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X8701500410
更新日期:1987-11-01 00:00:00
abstract::The effects of halothane (0.5-2%) and enflurane (1-4%) on two Transoxode transcutaneous oxygen (TcPO2) electrodes (Hellige Servomed Oxymonitor SM.361 system) were serially tested in atmospheres of nitrogen, air and 50% nitrous oxide in oxygen. Both TcPO2 electrodes reduced and "read" halothane but no enflurane. Calibr...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X8100900207
更新日期:1981-05-01 00:00:00
abstract::The development of an academic department of anaesthesia over its first ten years at McMaster Medical School in Hamilton, Ontario, Canada, is described. The organisation and goals of the department are described within the context of the regional organisation of health care delivery and of the functions of the faculty...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X8100900108
更新日期:1981-02-01 00:00:00
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journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X0303100104
更新日期:2003-02-01 00:00:00
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journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X0203000520
更新日期:2002-10-01 00:00:00
abstract::Purpura fulminans is a rare but devastating haemorrhagic condition often associated with sepsis. Many different organisms have been implicated in the aetiology of purpura fulminans, most commonly Neisseria meningitidis and Streptococcus pneumoniae. We report a case of purpura fulminans associated with Lactobacillus pa...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X0703500120
更新日期:2007-02-01 00:00:00
abstract::We reviewed the clinical characteristics, required intervention and short- and long-term outcomes in obstructive sleep apnoea (OSA) patients requiring intensive care. A retrospective, single-centre, observational cohort study was undertaken in a multidisciplinary teaching medical and surgical intensive care unit. Adul...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X1003800315
更新日期:2010-05-01 00:00:00
abstract::The efficacy of the McCoy laryngoscope, external laryngeal pressure, and their combination to improve the laryngoscopic view was evaluated in 219 patients and compared with the Macintosh laryngoscope. An experienced laryngoscopist performed laryngoscopy twice using the Macintosh laryngoscope and the McCoy laryngoscope...
journal_title:Anaesthesia and intensive care
pub_type: 临床试验,杂志文章
doi:10.1177/0310057X0002800509
更新日期:2000-10-01 00:00:00
abstract::In conscious subjects breathing spontaneously the performance of the Lack semi-closed system resembled the Magill attachment in that rebreathing was only detected at fresh gas flows of less than resting minute volume. With the Bain semi-closed system rebreathing was detectable at fresh gas flows of the order of 2.5 ti...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X8201000407
更新日期:1982-11-01 00:00:00
abstract::The ability of cricoid pressure to prevent inflation of the stomach during mask ventilation of a patient was studied. Fifty patients were randomly allocated to either have or not have cricoid pressure applied during a three-minute period of standardised mask ventilation. Patients who had had cricoid pressure applied h...
journal_title:Anaesthesia and intensive care
pub_type: 临床试验,杂志文章,随机对照试验
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更新日期:1988-05-01 00:00:00
abstract::A case of traumatic cerebral oedema is reported in which the infusion of small volumes of stable plasma protein solution (SPPS) resulted in acute and massive increases in intracranial pressure. The batch of SPPS responsible was found to have high levels of prekallikrein activator which is thought to be the cause of th...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X8000800416
更新日期:1980-11-01 00:00:00
abstract::Eighty-two patients presenting for major abdominal surgery were divided into five groups, and received intravenous ketamine, muscle relaxation and controlled ventilation with oxygen-enriched air. For maintenance of anaesthesia patients were given a single intravenous dose of either droperidol 5 mg, diazepam 5 mg, prom...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章
doi:10.1177/0310057X7800600308
更新日期:1978-08-01 00:00:00
abstract::We aimed to establish the frequency and nature of drug administration error in anaesthesia (a significant subset of error in medicine) at two hospitals. Anaesthetists were asked to return a study form anonymouslyfor every anaesthetic, indicating whether or not a drug administration error or pre-error (defined as any i...
journal_title:Anaesthesia and intensive care
pub_type: 杂志文章,多中心研究
doi:10.1177/0310057X0102900508
更新日期:2001-10-01 00:00:00