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Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.
ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3.
Journal Article > Study
Broom MA, Capek AL, Carachi P, Akeroyd MA, Hilditch G. Anaesthesia. 2011;66:175-179.
Journal Article > Review
Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment.
Weinger MB, Englund CE. Anesthesiology. 1990;73:995-1021.
This review discusses the important role ergonomic and human factors should play in ensuring safe anesthetic care, drawing on literature from non-health care settings. The authors begin by discussing errors in anesthesia and the opportunities created for such errors by the inevitable nature of the job. They continue by presenting a framework for the contributing factors, which include the work environment (eg, noise, lighting, temperature), the human component (eg, team factors, fatigue, workload), and the equipment and system component (eg, alarms, automation). The authors advocate for greater attention to these contributing factors and further study based on the experiences of other high-risk, error-prone industries.