Journal Article

Accident analysis of large-scale technological disasters applied to an anaesthetic complication.

Eagle CJ, Davies JM, Reason J. Canadian journal of anaesthesia = Journal canadien d'anesthesie. 1992;39:118-22.

Using methods to investigate disasters such as the Bhopal pesticide plant and the Challenger space shuttle, the authors of this study apply similar techniques to examine errors in anesthesia. The model discussed focuses on two types of failures, which share equal importance in analysis but distinguish the necessary avenues for intervention. The first, active failures, consists of mistakes made by providers in the delivery of care. The second, latent failures, represents flaws in the systems of care. The authors use a case example in anesthesia to illustrate how searching for active failures alone fails to prevent future events. They conclude that analysis of past disasters has offered a useful model to differentiate provider from organizational failures, a process that continues to be emphasized in patient safety efforts today.