Fatal errors in nitrous oxide delivery.

H. Herff; P. Paal; A. Von Goedecke; K. H Lindner; C. Keller; V. Wenzel

Review

Fatal errors in nitrous oxide delivery.

January 2, 2008

Herff H, Paal P, Von Goedecke A, et al. Anaesthesia. 2007;62(12):1202-1206.

View more articles from the same authors.

This review assessed published evidence along with media reports to analyze incidents of nitrous oxide–related anesthesia errors.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Human factors in anaesthesia: a narrative review.

February 15, 2023

Five-year audit of adherence to an anaesthesia pre-induction checklist.

March 30, 2022

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

March 1, 2023

How can never event data be used to reflect or improve hospital safety performance?

May 19, 2021

Nursing and patient safety in the operating room.

January 23, 2008

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008.

August 31, 2011

Cognitive aids in the management of clinical emergencies: a systematic review.

January 18, 2023

Missed nursing care during the COVID-19 pandemic: a comparative observational study.

July 21, 2021

Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias.

March 22, 2023

Effects of extended work shifts and shift work on patient safety, productivity, and employee health.

February 10, 2010

A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist.

February 2, 2022

Mental health of staff working in intensive care during COVID-19.

February 24, 2021

Impact of the initial response to COVID-19 on long-term care for people with intellectual disability: an interrupted time series analysis of incident reports.

October 14, 2020

Attitudes of health sciences faculty members towards interprofessional teamwork and education.

September 5, 2007

A health system that won't learn from its mistakes.

September 21, 2022

Countering cognitive biases in minimising low value care.

June 7, 2017

Effectiveness of communication interventions in obstetrics--a systematic review.

April 21, 2021

Psychological intervention to improve communication and patient safety in obstetrics: examination of the health action process approach.

April 13, 2022

Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017.

December 16, 2020

Habit and automaticity in medical alert override: cohort study.

April 27, 2022

Clinical and economic impacts of explicit tools detecting prescribing errors: a systematic review.

May 26, 2021

The association between nurse staffing and omissions in nursing care: a systematic review.

July 11, 2018

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice.

October 12, 2016

Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings.

June 16, 2021

Special Issue on Resilience Engineering and High Reliability Organizations.

August 7, 2019

Medication dose calculation errors and other numeracy mishaps in hospitals: analysis of the nature and enablers of incident reports.

November 10, 2021

Transformational leadership in nursing and medication safety education: a discussion paper.

June 1, 2016

The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis.

September 9, 2020

Clinically significant medication errors in surgical units detected by clinical pharmacist: a real-life study.

November 10, 2021

Development of a core drug list towards improving prescribing education and reducing errors in the UK.

March 2, 2011

Nurses' experiences of organizational learning.

August 19, 2020

Older adults' awareness of deprescribing: a population-based survey.

February 28, 2018

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

September 22, 2021

Factors associated with workarounds in barcode-assisted medication administration in hospitals.

August 26, 2020

Organizing for Reliability: A Guide for Research and Practice.

January 30, 2019

Self-reported adherence to high reliability practices among participants in the Children's Hospitals' Solutions for Patient Safety Collaborative.

December 12, 2018

The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative.

October 20, 2021

Perioperative medication errors: uncovering risk from behind the drapes.

January 16, 2019

Patient safety and the question of dignitary harms.

March 15, 2023

Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK.

May 5, 2010

Medication reconciliation in ambulatory oncology.

December 5, 2007

Quality of life after maternal near miss: a systematic review.

June 2, 2021

Assessment of changes in visits and antibiotic prescribing during the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic.

July 20, 2022

Optimising the delivery of remediation programmes for doctors: a realist review.

June 2, 2021

Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders.

November 7, 2007

Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment.

January 26, 2022

The impact of health information management professionals on patient safety: a systematic review.

December 22, 2021

A case of the birth and death of a high reliability healthcare organisation.

June 22, 2005

Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology: a meta-analysis and review.

December 1, 2005

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services.

December 7, 2022

Humanizing harm: using a restorative approach to heal and learn from adverse events.

May 4, 2022

The nurse's experience of decision-making processes in missed nursing care: a qualitative study.

May 13, 2020

Parent-reported errors and adverse events in hospitalized children.

March 16, 2016

Health professionals' perspectives of safety issues in mental health services: a qualitative study.

March 31, 2021

Errors in medication history at hospital admission: prevalence and predicting factors.

June 20, 2012

Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care.

March 17, 2021

Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.

May 19, 2021

Developing critical thinking skills for delivering optimal care

July 28, 2021

Structural empowerment and patient safety culture among registered nurses working in adult critical care units.

November 3, 2010

Prevent medication errors: a New Year's resolution: teaching patients about their medications.

January 31, 2007

Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high-income countries.

March 3, 2021

Prescribing decision making by medical residents on night shifts: a qualitative study.

November 9, 2022

Factors associated with missed nursing care and nurse-assessed quality of care during the COVID-19 pandemic.

February 23, 2022

Association between parent comfort with English and adverse events among hospitalized children.

November 11, 2020

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses.

November 25, 2020

12 h shifts and rates of error among nurses: a systematic review.

August 5, 2015

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

March 24, 2010

Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review.

June 9, 2021

Medication safety in older adults: home-based practice patterns.

June 22, 2005

Improving communication and teamwork during labor: a feasibility, acceptability, and safety study.

March 16, 2022

Transforming the medication regimen review process using telemedicine to prevent adverse events.

December 16, 2020

Factors associated with workplace violence among healthcare workers in an academic medical center.

April 27, 2022

Standardized assessment of medication reconciliation in post-acute care.

April 27, 2022

Nursing student errors and near misses: three years of data.

February 22, 2023

Registered nurses' perceptions of safe care in overcrowded emergency departments.

May 16, 2018

Positive approaches to safety: learning from what we do well.

August 31, 2022

Neonatal near-miss audits: a systematic review and a call to action.

January 10, 2024

Effect of communication errors during calls to an antimicrobial stewardship program.

March 26, 2008

Two fatal cases of accidental intrathecal vincristine administration: learning from death events.

January 6, 2016

Medication use and cognitive impairment among residents of aged care facilities.

June 23, 2021

Incidence of prescription errors in patients discharged from the emergency department.

September 22, 2021

Factors associated with wrong blood in tube errors: an international case series - The BEST collaborative study.

November 17, 2021

Harms from discharge to primary care: mixed methods analysis of incident reports.

December 16, 2015

Core competencies for patient safety research: a cornerstone for global capacity strengthening.

February 2, 2011

Nurses' perceptions of safety culture in long-term care settings.

July 8, 2009

Emergency departments are higher-risk locations for wrong blood in tube errors.

September 29, 2021

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.

February 6, 2008

Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital.

August 22, 2018

Establishing psychological safety in clinical supervision: multi-professional perspectives.

May 11, 2022

Implementation, CPOE, and medication errors.

June 8, 2005

The effect of the fit between organizational culture and structure on medication errors in medical group practices.

February 7, 2007

Root causes of adverse drug events in hospitals and artificial intelligence capabilities for prevention.

May 5, 2021

Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia.

August 24, 2022

Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents.

September 14, 2022

Medication prescribing errors in a teaching hospital.

March 6, 2005

Pediatric musculoskeletal radiographs: anatomy and fractures prone to diagnostic error among emergency physicians.

August 3, 2022

Workplace verbal abuse, nurse-reported quality of care, and patient safety outcomes among early-career hospital nurses.

August 19, 2020

The radiology impact of healthcare errors during shift work.

October 28, 2020

Differences in medication reconciliation interventions between six hospitals: a mixed method study.

June 29, 2022

Staffing, teamwork and scope of practice: analysis of the association with patient safety in the context of rehabilitation.

December 15, 2021

Related Resources

Debriefing to improve interprofessional teamwork in the operating room: a systematic review.

March 6, 2024

Shining a glaring light on surgery: technology that records every move aims to improve safety.

January 24, 2024

Perioperative team-based morbidity and mortality conferences: a systematic review of the literature.

October 11, 2023

Fire safety in the operating room.

October 1, 2023

Perioperative handoff enhancement opportunities through technology and artificial intelligence: a narrative review.

June 14, 2023

Green Cross method in a postanaesthesia care unit: a qualitative study of the healthcare professionals' experiences after 3 years, including the COVID-19 pandemic period.

June 14, 2023

Cognitive biases in surgery: systematic review.

March 1, 2023

Human factors in anaesthesia: a narrative review.

February 15, 2023

WebM&M Cases

Intraosseous Line Extravasation in a Pediatric Trauma Patient

April 27, 2022

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

April 27, 2022

Performance variability in perioperative sentinel events: report on a nationwide data set.

April 20, 2022

Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial.

February 9, 2022

Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational survey.

November 17, 2021

Communication failures contributing to patient injury in anaesthesia malpractice claims.

September 1, 2021

Systematic review of intraoperative anesthesia handoffs and handoff tools.

July 21, 2021

WebM&M Cases

Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia

June 30, 2021

Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation.

June 9, 2021

Safety and Quality in Perioperative Anesthesia Care.

April 7, 2021

Sex and gender differences in anesthesia: relevant also for perioperative safety?

April 7, 2021

Outcomes from Wake Up Safe, the pediatric anesthesia quality improvement initiative.

February 3, 2021

Automation failures and patient safety.

December 2, 2020

Real-time debriefing after critical events: exploring the gap between principle and reality.

November 18, 2020

The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue.

November 11, 2020

Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management.

April 22, 2020

How does the WHO Surgical Safety Checklist fit with existing perioperative risk management strategies? An ethnographic study across surgical specialties.

March 18, 2020

When is a doctor too old for the job?

September 18, 2019

Analysis of human performance deficiencies associated with surgical adverse events.

August 14, 2019

Impact of the World Health Organization surgical safety checklist on patient safety.

June 12, 2019

Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications.

May 8, 2019

Office-based surgery and patient outcomes.

March 27, 2019

See More About The Topic

Fatal errors in nitrous oxide delivery.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Fatal errors in nitrous oxide delivery.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site