Journal Article

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

Neily J; Silla ES; Sum-Ping SJT; Reedy R; Paull DE; Mazzia L; Mills PD; Hemphill RR.

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.