Failed spinal anaesthesia: mechanisms, management, and prevention.

P. D W Fettes; J-R Jansson; J. A W Wildsmith

Review

Failed spinal anaesthesia: mechanisms, management, and prevention.

July 8, 2009

Fettes PDW, Jansson J-R, Wildsmith JAW. Br J Anaesth. 2009;102(6):739-48.

View more articles from the same authors.

This review surveys common risks involved with spinal anesthesia and describes strategies to minimize errors and address failures when they occur.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Adverse events associated with patient isolation: a systematic literature review and meta-analysis.

January 19, 2022

Unscheduled return visits to the emergency department with ICU admission: a trigger tool for diagnostic error.

December 4, 2019

Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review.

November 10, 2021

Patients who die by suicide: a study of treatment patterns and patient safety incidents in Norway.

November 9, 2022

Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study.

May 24, 2023

Assessing safety culture: guidelines and recommendations.

August 17, 2005

Unintended doses in radiotherapy—over, under and outside?

April 18, 2018

Requirements for the design and implementation of checklists for surgical processes.

August 13, 2008

Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system.

February 20, 2008

Unplanned return to theater: a quality of care and risk management index?

May 27, 2015

Barriers to incident notification in a regional prehospital setting.

July 28, 2010

Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems.

December 13, 2006

Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK.

May 5, 2010

Cognitive errors detected in anaesthesiology: a literature review and pilot study.

January 25, 2012

Disclosing adverse events in clinical practice: the delicate act of being open.

February 2, 2022

Uncomfortable prescribing decisions in hospitals: the impact of teamwork.

November 25, 2009

Ethics, oversight and quality improvement initiatives.

August 25, 2010

Interventions to improve teamwork and communications among healthcare staff.

March 2, 2011

Decision-making and safety in anesthesiology.

November 21, 2012

Expanded pharmacy technician roles: accepting verbal prescriptions and communicating prescription transfers.

February 1, 2017

Time for prefilled syringes - everywhere.

March 13, 2024

Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center data.

November 22, 2006

The medicolegal aspect of error in pathology: a search of jury verdicts and settlements.

April 25, 2007

Patient safety in cataract surgery.

July 20, 2005

Cognitive errors in diagnosis: instantiation, classification, and consequences.

March 6, 2005

Computerized physician order entry: helpful or harmful?

March 6, 2005

Medication errors: the impact of prescribing and transcribing errors on preventable harm in hospitalised patients.

March 4, 2009

Patient risk factors for medical injury: a case–control study.

January 26, 2011

Sex differences in operating room care giver perceptions of patient safety: a pilot study from the Veterans Health Administration Medical Team Training Program.

March 3, 2010

Beyond 'find and fix': improving quality and safety through resilient healthcare systems.

April 15, 2020

Impact of the initial response to COVID-19 on long-term care for people with intellectual disability: an interrupted time series analysis of incident reports.

October 14, 2020

Hand-off communication: a requisite for perioperative patient safety.

November 19, 2008

Medication reconciliation in the emergency department: opportunities for workflow redesign.

December 15, 2010

Detecting drug interactions using personal digital assistants in an out-patient clinic.

October 31, 2007

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections.

June 14, 2017

Medication errors with antituberculosis therapy in an inpatient, academic setting: forgotten but not gone.

February 10, 2016

Ranking hospitals based on preventable hospital death rates: a systematic review with implications for both direct measurement and indirect measurement through standardized mortality rates.

April 3, 2019

Leading article: how can I optimise my role as a leader within the surgical team?

August 31, 2016

Novel analysis of clinically relevant diagnostic errors in point-of-care devices.

October 19, 2011

Development and measurement of perioperative patient safety indicators.

March 18, 2015

Variation in caregiver perceptions of teamwork climate in labor and delivery units.

July 5, 2006

Enhanced morbidity and mortality meeting and patient safety education for specialty trainees.

August 12, 2015

Systematic review of serious games for medical education and surgical skills training.

November 21, 2012

Medication administration process assessment: applying lessons learned from commercial aviation.

March 11, 2009

Levels of agreement on the grading, analysis and reporting of significant events by general practitioners: a cross-sectional study.

October 29, 2008

What is the patient really taking? Discrepancies between surgery and anesthesiology preoperative medication histories.

December 21, 2005

Improving the quality of written prescriptions in a general hospital: the influence of 10 years of serial audits and targeted interventions.

April 30, 2008

The incidence and cost of adverse events in Victorian hospitals 2003-04.

June 28, 2006

A qualitative study of why general practitioners may participate in significant event analysis and educational peer assessment.

June 29, 2005

Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies.

March 27, 2005

The heart of darkness: the impact of perceived mistakes on physicians.

March 6, 2005

Radiology errors: are we learning from our mistakes?

October 7, 2009

Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center.

March 6, 2005

Impact of teamwork and communication training interventions on safety culture and patient safety in emergency departments: a systematic review.

January 26, 2022

The active components of effective training in obstetric emergencies.

June 10, 2009

A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients.

December 6, 2006

Development and usability of a behavioural marking system for performance assessment of obstetrical teams.

November 4, 2009

Surgical adverse outcome reporting as part of routine clinical care.

May 19, 2010

Why patient safety is such a tough nut to crack.

July 6, 2011

Resilience in healthcare and clinical handover.

August 12, 2009

Survey evaluation of the National Patient Safety Agency’s Root Cause Analysis training programme in England and Wales: knowledge, beliefs and reported practices.

August 26, 2009

The impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review.

June 22, 2016

Beyond FMEA: the structured what-if technique (SWIFT).

September 26, 2012

How should medication errors be defined? Development and test of a definition.

May 30, 2012

Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital.

August 22, 2018

Quantifying and monitoring overdiagnosis in cancer screening: a systematic review of methods.

January 21, 2015

Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a tracheostomy.

July 18, 2007

Should operations be regionalized? The empirical relation between surgical volume and mortality.

March 6, 2005

Iatrogenic illness on a general medical service at a university hospital.

March 27, 2005

Current and emerging infectious risks of blood transfusions.

March 27, 2005

The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study.

November 10, 2010

Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about.

October 21, 2015

Deviation from a preoperative surgical and anaesthetic care plan is associated with increased risk of adverse intraoperative events in major abdominal surgery.

December 5, 2012

April 8, 2009

Getting doctors to report medical errors: project DISCLOSE.

July 5, 2006

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

October 20, 2010

Quantification of surgical resident stress "on call".

November 30, 2005

Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery.

April 3, 2005

Preventing catheter-related bloodstream infections outside the intensive care unit: expanding prevention to new settings.

July 21, 2010

How to monitor patient safety in primary care? Healthcare professionals' views.

October 19, 2016

The relationship of self-report of quality to practice size and health information technology.

October 10, 2012

High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process.

November 2, 2011

The use of pharmaceuticals for dialysis patients. How well do we know our patients' allergies?

March 11, 2009

Targeting zero harm: a stretch goal that risks breaking the spring.

August 12, 2020

Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals.

January 20, 2016

Attitudes and barriers to incident reporting: a collaborative hospital study.

February 22, 2006

More to teamwork than knowledge, skill and attitude.

September 1, 2010

Crew resource management in the intensive care unit: a prospective 3-year cohort study.

July 1, 2015

Perceptions of preventable medical errors in Alberta, Canada.

January 30, 2008

Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality.

March 27, 2005

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

May 26, 2010

Error rating tool to identify and analyse technical errors and events in laparoscopic surgery.

September 11, 2013

Patient outcomes after the introduction of statewide ICU nurse staffing regulations.

September 26, 2018

Building a community engagement approach for patient safety improvement.

January 7, 2015

Evaluation of an anonymous system to report medical errors in pediatric inpatients.

August 22, 2007

Processes for effective communication in primary care.

May 4, 2005

A systematic review of interventions to follow-up test results pending at discharge.

February 7, 2018

Outcomes are worse in US patients undergoing surgery on weekends compared with weekdays.

July 20, 2016

The economic consequences of medical injuries: implications for a no-fault insurance plan.

March 6, 2005

An intervention to decrease patient identification band errors in a children's hospital.

May 12, 2010

Related Resources

Safety and Human Performance in the Operating Room and Other Extreme Environments.

March 27, 2024

Guidelines on Human Factors in Critical Situations 2023.

August 9, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence.

April 12, 2023

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

March 1, 2023

Human factors in anaesthesia: a narrative review.

February 15, 2023

Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid scoping review.

December 14, 2022

Improving safety in the operating room: medication icon labels increase visibility and discrimination.

November 2, 2022

Eliminating Unintentionally Retained Surgical Items - Special Report.

September 21, 2022

WebM&M Cases

Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy

August 31, 2022

Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes.

June 1, 2022

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

April 27, 2022

WebM&M Cases

Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room

April 27, 2022

Disclosing adverse events in clinical practice: the delicate act of being open.

February 2, 2022

Pediatric medication errors and reduction strategies in the perioperative period.

November 24, 2021

WebM&M Cases

Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected

August 25, 2021

Enhancing a culture of safety through disclosure of adverse events.

March 10, 2021

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients.

March 10, 2021

Prioritising recommendations following analyses of adverse events in healthcare: a systematic review.

November 4, 2020

Scoping review of patients' attitudes about their role and behaviours to ensure safe care at the direct care level.

August 26, 2020

Disclosing and reporting practice errors by nurses in residential long-term care settings: a systematic review.

June 10, 2020

Putting the patient in patient safety investigations: barriers and strategies for involvement.

June 3, 2020

Patterns in medication incidents: a 10-yr experience of a cross-national anaesthesia incident reporting system.

December 18, 2019

The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse.

July 24, 2019

Quality and Safety in Anesthesia and Perioperative Care.

July 17, 2019

Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia.

June 5, 2019

Medicines safety in anaesthetic practice.

May 22, 2019

People, systems and safety: resilience and excellence in healthcare practice.

April 17, 2019

Prescribing in 2019: what are the safety concerns?

March 13, 2019

See More About The Topic

Operating Room

Health Care Providers

Quality and Safety Professionals

Anesthesiology

Medication Errors/Preventable Adverse Drug Events

Failed spinal anaesthesia: mechanisms, management, and prevention.

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Failed spinal anaesthesia: mechanisms, management, and prevention.

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site