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Journal Article > Review
Patel S, Robertson B, McConachie I. Anaesthesia. 2019;74:904-914.
Medication administration mistakes can result in serious patient harm. This review explored human factors that contribute to spinal anesthesia administration errors. The authors documented organizational, supervisory, system, and individual factors that contributed to errors. They recommend strategies to prevent such incidents, including the use of double checks and improved labeling practices.
Journal Article > Study
Simulation-based event analysis improves error discovery and generates improved strategies for error prevention.
Lobos AT, Ward N, Farion KJ, et al. Simul Healthc. 2019 May 21; [Epub ahead of print].
Root cause analysis (RCA) is a vital tool to assess errors and prevent their recurrence. However, many have identified limitations to traditional RCAs. This study found that when RCA was adapted into a simulation format and compared to traditional RCA, simulation participants identified novel sources of error as well as creative solutions.