Taking a Human Factors Engineering Approach to Improve Anesthesia Safety

February 21, 2018 | Strategic Insights for Health System


​Although anesthesia is one of the safest medical specialties, gaps still exist that may be filled through system-wide implementation of human factors engineering approaches, according to a study published in the February 2018 issue of Anesthesia & Analgesia. Anesthesia providers were "pioneers" in patient safety, the authors said, and this work has led to improvement in operative mortality. However, anesthesia-related adverse events remain, which can lead to malpractice claims, permanent injury, and death. The authors analyzed root-cause analyses (RCAs) from Veterans Health Administration hospitals from May 30, 2012, through May 1, 2015, for root causes, severity of patient outcomes, and actions taken. In 36 RCA reports of adverse events specific to anesthesia care, 5 (14%) were identified as being catastrophic and 10 (28%) were identified as major.

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