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 Adverse Events Voluntarily Reported in the Veterans Health Administration and Lessons Learned. Anesth Analg. 2017;126(2):471-477. doi:10.1213/ane.0000000000002149.
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.