Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting.
Smith AF, Goodwin D, Mort M, et al. Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting. Br J Anaesth. 2006;96(6):715-21.
The authors interviewed and observed anesthetists and anesthesia staff to determine what were considered critical incidents and how this understanding influenced reporting of and learning from events.