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

Julia Neily; Elda S Silla; Sam (John) T Sum-Ping; Roberta Reedy; Douglas E. Paull; Lisa Mazzia; Peter D. Mills; Robin R. Hemphill

Study

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

August 23, 2017

Neily J, Silla ES, Sum-Ping S (J) T, et al. Anesth Analg. 2017;126(2):471-477.

View more articles from the same authors.

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.

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Medication Errors/Preventable Adverse Drug Events

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