Missed steps in the preanesthetic set-up.
DeMaria S, Blasius K, Neustein SM. Missed steps in the preanesthetic set-up. Anesth Analg. 2011;113(1):84-8. doi:10.1213/ANE.0b013e318219645e.
Anesthesia equipment was often improperly set up, potentially exposing patients to safety risks. Production pressures may have played a role in these results.