Journal Article
Study

Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned.

Neily J, Silla ES, Sum-Ping S (J) T, et al. Anesthesia & Analgesia. 2017;126.

This study examined root cause analyses performed by the Veterans Health Administration to identify and characterize anesthesia-related safety events. Although a relatively small number of events were found, the authors identified several human factors solutions that, if implemented, could prevent common types of errors.