Customer focused incident monitoring in anaesthesia.

F. A. Khan; S. Khimani

Study

Customer focused incident monitoring in anaesthesia.

June 6, 2007

Khan FA, Khimani S. Anaesthesia. 2007;62(6):586-90.

View more articles from the same authors.

The authors studied anesthesia-related incident reports at one institution and found that many incidents were related to communication, behavior, and delays in service.

PubMed citation

Available at

Related Resources From the Same Author(s)

An overview of the use and implementation of checklists in surgical specialities - a systematic review.

February 25, 2015

Communication and shared understanding between parents and resident-physicians at night.

July 13, 2016

A piece of my mind. A death in the family.

November 1, 2017

Improving medication safety in the ICU: the pharmacist's role.

May 16, 2007

Development and content validation of a surgical safety checklist for operating theatres that use robotic technology.

July 31, 2013

Promoting patient safety through prospective risk identification: example from peri-operative care.

March 17, 2010

Involving users in the design of a system for sharing lessons from adverse incidents in anaesthesia.

April 5, 2006

Communication outcomes of critical imaging results in a computerized notification system.

May 16, 2007

Early warning scores to predict noncritical events overnight in hospitalized medical patients: a prospective case cohort study.

September 23, 2020

A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist.

October 30, 2013

Intra-operative monitoring—many alarms with minor impact.

September 18, 2013

Enhancing medication use safety: benefits of learning from your peers.

October 21, 2009

Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?

March 17, 2010

Effectiveness of ChatGPT in clinical pharmacy and the role of artificial intelligence in medication therapy management.

February 7, 2024

Building a safety culture.

December 21, 2005

Does the perception of severity of medical error differ between varying levels of clinical seniority?

October 3, 2018

A comprehensive obstetric patient safety program reduces liability claims and payments.

June 25, 2014

Cognitive biases regarding utilization of Emergency Severity Index among emergency nurses.

October 4, 2023

Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment.

September 29, 2021

Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports.

January 7, 2009

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

November 17, 2010

A "Do No Harm" novel safety checklist and research approach to determine whether to launch an artificial intelligence-based medical technology: introducing the Biological-Psychological, Economic, and Social (BPES) Framework.

July 5, 2023

Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?

October 7, 2009

Compliance to technical guidelines for radiotherapy treatment in relation to patient safety.

May 19, 2010

Lessons from "unexpected increased mortality after implementation of a commercially sold computerized physician order entry system."

August 16, 2006

A systematic review of trauma crew resource management training: what can the United States and the United Kingdom learn from each other?

September 2, 2020

Using a quantitative risk register to promote learning from a patient safety reporting system.

February 4, 2015

Impact of a comprehensive patient safety strategy on obstetric adverse events.

March 18, 2009

Doctors' views of attitudes towards peer medical error.

June 17, 2009

Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients' safety: assessor-blind pilot comparison.

February 25, 2009

The role of physician specialty board certification status in the quality movement.

March 6, 2005

Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.

February 13, 2019

Is oral chemotherapy prescription safe for patients? A cross-sectional survey.

May 7, 2014

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

April 17, 2019

Parent-reported errors and adverse events in hospitalized children.

March 16, 2016

Parent–provider miscommunications in hospitalized children.

August 23, 2017

An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study.

November 26, 2014

Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.

September 8, 2010

Assessing system failures in operating rooms and intensive care units.

March 7, 2007

Surgical skill is predicted by the ability to detect errors.

May 25, 2005

Facilitation of surgical innovation: is it possible to speed the introduction of new technology while simultaneously improving patient safety?

April 24, 2019

Evaluation of frequency of paediatric oral liquid medication dosing errors by caregivers: amoxicillin and josamycin.

March 9, 2016

Disclosure and reporting of surgical complications: a double-edged sword?

August 18, 2010

The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support.

June 16, 2010

Detection of adverse events in surgical patients using the Trigger Tool approach.

August 27, 2008

Measuring team performance in healthcare: review of research and implications for patient safety.

June 25, 2008

A tragic death: a time to blame or a time to learn?

March 6, 2005

Patient safety: latent risk factors.

July 14, 2010

The Psychiatry Morbidity and Mortality Incident Reporting Tool increases psychiatrist participation in reporting adverse events.

September 26, 2018

Designing safety interventions for specific contexts: results from a literature review.

October 26, 2022

Surgical confusions in ophthalmology.

November 14, 2007

Epidemiology of malpractice lawsuits in paediatrics.

July 2, 2008

Structured patient handoff on an internal medicine ward: a cluster randomized control trial.

July 25, 2018

ASHP guidelines: minimum standard for ambulatory care pharmacy practice.

July 22, 2015

Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy.

March 22, 2017

Clinical decision support: a 25 year retrospective and a 25 year vision.

September 14, 2016

Distraction and interruption in anaesthetic practice.

January 23, 2013

The effect of audible alarms on anaesthesiologists' response times to adverse events in a simulated anaesthesia environment: a randomised trial.

June 18, 2014

Analysis of patient-physician concordance in the understanding of chemotherapy treatment plans among patients with cancer.

March 25, 2020

Identifying diagnostic errors in primary care using an electronic screening algorithm.

February 21, 2007

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

March 27, 2005

Same-hospital readmission rates as a measure of pediatric quality of care.

August 12, 2015

Literacy and misunderstanding prescription drug labels.

December 13, 2006

Patient safety and systematic reviews: finding papers indexed in MEDLINE, EMBASE and CINAHL.

November 24, 2010

Medication overdoses leading to emergency department visits among children.

August 26, 2009

The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.

July 29, 2009

Overarching goals: a strategy for improving healthcare quality and safety?

December 19, 2012

Second victims need emotional support after adverse events: even in a just safety culture.

April 3, 2019

The problem with making Safety-II work in healthcare.

April 13, 2022

Serious experience events: applying patient safety concepts to improve patient experience.

July 6, 2022

Adoption of health information technology for medication safety in US hospitals, 2006.

May 28, 2008

Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm.

April 13, 2022

Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems.

March 4, 2009

Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback.

January 14, 2009

Making the Patient Safety and Quality Improvement Act of 2005 work.

September 26, 2007

Cluster randomized trial to evaluate the impact of team training on surgical outcomes.

October 5, 2016

A comprehensive obstetrics patient safety program improves safety climate and culture.

April 20, 2011

Emergency department crowding and risk of preventable medical errors.

May 16, 2012

Association between electronic medical record implementation of default opioid prescription quantities and prescribing behavior in two emergency departments.

February 7, 2018

A simulation design for research evaluating safety innovations in anaesthesia.

January 28, 2009

Improving prescription drug warnings to promote patient comprehension.

January 20, 2010

The high cost of low-frequency events: the anatomy and economics of surgical mishaps.

March 27, 2005

ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery.

October 28, 2009

The problem with using patient complaints for improvement.

January 17, 2018

Essential activities for electronic health record safety: a qualitative study.

March 20, 2019

Learning from morbidity and mortality conferences: focus and sustainability of lessons for patient care.

April 28, 2021

Impact of contact isolation for multidrug-resistant organisms on the occurrence of medical errors and adverse events.

October 23, 2013

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

November 9, 2022

Common general surgical never events: analysis of NHS England never event data.

April 7, 2021

Factors influencing diagnostic accuracy among intensive care unit clinicians - an observational study.

January 24, 2024

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008.

August 31, 2011

New unintended adverse consequences of electronic health records.

July 19, 2017

Clinical faculty: taking the lead in teaching quality improvement and patient safety.

October 8, 2014

Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room.

July 2, 2008

Using system analysis to build a safety culture: improving the reliability of epidural analgesia.

October 11, 2006

Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting.

May 31, 2006

Are incorrectly used drugs more frequently involved in adverse drug reactions? A prospective study.

May 4, 2005

Effect of outcome on physician judgments of appropriateness of care.

March 6, 2005

Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners.

May 28, 2014

Global oximetry: an international anaesthesia quality improvement project.

October 21, 2009

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Preoperative communication between anesthesia, surgery, and primary care providers for older surgical patients.

March 6, 2024

Perspective

Patient Safety in Office-Based Care Settings

January 31, 2024

Interview

In Conversation with...Richard Ricciardi about Office-Based Patient Safety

January 31, 2024

On Patient Safety.

November 7, 2023

Anesthesia Risk Alert program: a proactive safety initiative.

August 30, 2023

Guidelines on Human Factors in Critical Situations 2023.

August 9, 2023

Use of technology to improve the adherence to surgical safety checklists in the operating room.

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Compliance with and barriers to implementing the surgical safety checklist: a mixed-methods study.

March 8, 2023

Trial and error: learning from malpractice claims in childhood surgery.

August 24, 2022

Non-technical skills in surgery during the COVID-19 pandemic: an observational study.

March 9, 2022

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.

November 17, 2021

Communication failures contributing to patient injury in anaesthesia malpractice claims.

September 1, 2021

WebM&M Cases

Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected

August 25, 2021

WebM&M Cases

Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia

June 30, 2021

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

March 10, 2021

Outcomes from Wake Up Safe, the pediatric anesthesia quality improvement initiative.

February 3, 2021

Implicit bias in stroke care: a recurring old problem in the rising incidence of young stroke.

January 27, 2021

Awareness of human factors in the operating theatres during the COVID-19 pandemic.

January 13, 2021

Opioid stewardship program and postoperative adverse events: a difference-in-differences cohort study.

September 16, 2020

What is an ethically informed approach to managing patient safety risk during discharge planning?

January 20, 2020

WebM&M Cases

"Do You Want Everything Done?": Clarifying Code Status

December 18, 2019

Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study.

November 6, 2019

Analysis of human performance deficiencies associated with surgical adverse events.

August 14, 2019

Exposure to incivility hinders clinical performance in a simulated operative crisis.

June 26, 2019

Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia.

June 5, 2019

Learning From Invited Reviews.

April 10, 2019

A qualitative evaluation of healthcare professionals' perceptions of adverse events focusing on communication and teamwork in maternity care.

March 27, 2019

Failure to debrief after critical events in anesthesia is associated with failures in communication during the event.

March 20, 2019

See More About The Topic

Discontinuities, Gaps, and Hand-Off Problems

Customer focused incident monitoring in anaesthesia.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Customer focused incident monitoring in anaesthesia.

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