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Canadian Anaesthetists’ Society Journal

, Volume 26, Issue 6, pp 472–478 | Cite as

Human misadventure in anaesthesia

  • J. E. Utting
  • T. C. Gray
  • F. C. Shelley
Article

Summary

An account is given of the 602 anaesthetic accidents reported to the Medical Defence Union of the United Kingdom over the eight-year period 1970-1977: these were reported from a total membership of 2,000 anaesthetists. It is known that reporting of minor accidents, for example damage to teeth, is very imcomplete, and that many deaths associated with surgery but due to disease processes rather than anaesthesia would not be reported either. It is thought, however, that the reporting by members of other accidents involving death and cerebral damage is likely to be complete, or nearly so.

Cases of death and cerebral damage reported numbered 348 (60 per cent of the total) and the causes of these two major accidents were so closely similar that it was possible to deal with them together. This appears to be a suitable approach since cerebral damage can be as great, or greater, a catastrophe than death. In nearly half of this group of accidents there was discernibly faulty technique. Failure of postoperative care ( 10 per cent of the 348 cases) was another prominent and avoidable cause.

Analysis of the faulty anaesthetic techniques which led to these major accidents showed that factors involved in tracheal intubation were preeminent, and that misuse of apparatus was also conspicuous. Over all error was deemed to be twice as common a cause of death and cerebral damage as was misadventure.

Keywords

Halothane Tracheal Intubation Medical Defence Cerebral Damage Major Accident 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Résumé

Entre 1970 et 1977, 602 accidents anesthésiques ont été rapportés au Medical Defense Union qui représente environ 87,000 médecins et dentistes (dont 2,000 anesthésistes) dans les cas de poursuites liées à la pratique de leur profession.

Il est clair que ce total ne représente pas la totalité des accidents survenus. En effet, beaucoup ďaccidents mineurs, comme les traumatismes dentaires, ne sont probablement pas rapportés. De même, on ne rapporte généralement pas les décçs clairement liés à une pathologie pré-existante. Par ailleurs, il apparaït probable que la presque totalité des accidents suivis de décçs ou de dommages cérébraux sont effectivement rapportés.

De tels accidents (suivis de décçs ou de dommages cérébraux) représentaient 60 pour cent du total, soit 318 cas sur 602. Les causes de ces deux types ďaccidents étaient si semblables que ľon a choisi de les considérer dans un même ensemble. Cette approche apparaït justifiée lorsque ľon considçre qu’un cas de dommage cérébral peut être aussi catastrophique qu’un décçs.

Dans près de la moitié de ces accidents graves, on a pu mettre en évidence une faute technique (tube trachéal dans ľœsophage ou incapacité ďintuber et de ventiler un malade obstrué aprçs ľavoir endormi et cu rari sé, aspiration de contenu gastrique, respirateur ou tubes ďappareil ďanesthésie débranchés, cylindres ďoxygçne épuisés, usage du protoxyde ďazote alors que ľon croyait utiliser ľoxygçne, etc). Dix pour cent des cas sont survenus en phase post-opératoire (surtout des problçmes ďobstruction des voies aériennes. Par comparaison aux situations peu prévisibles (hyperthermic maligne, hépatites à ľhalothane) reliées à la pathologie préexistante, ľerreur humaine était en cause dans une proportion de deux pour un.

References

  1. Beecher. H.K. &Todd. D.P. A study of the deaths associated with anesthesia and surgery based on a study of 599,548 anesthesias in ten institutions 1948-1952. inclusive. Ann. Surg.140: 2–35 (1954).PubMedCrossRefGoogle Scholar
  2. Boba, A. Death in the Operating Room. Springfield, III., Charles C. Thomas (1965).Google Scholar
  3. Clifton, B.S. &Hotten, W.I.T. Deaths associated with anesthesia. Br. J. Anaesth.35: 250–259 (1963).PubMedCrossRefGoogle Scholar
  4. Cooper, J.B., Newbower, R.S., Long, CD. &McPeek. B. Preventable anesthesia mishaps: a study of human factors. Anesthesiology,49: 399–406 (1978).PubMedCrossRefGoogle Scholar
  5. Dripps, R.D., Lamont, A. &Eckenhoff. J.E. The role of anesthesia in surgical mortality. J.A.M.A.178: 261–266 (1961).PubMedGoogle Scholar
  6. Edwards, G., Morton, H.J.V. &Pask. E.A..et al. Deaths associated with anesthesia: report on 1,000 cases. Anaesthesia11: 194–220 (1956).PubMedCrossRefGoogle Scholar
  7. Phillips. O.C. &Capizzi, L.S. Anesthesia mortality. Clin. Anesth.10: 220–244 (1974).PubMedGoogle Scholar
  8. Taylor, G., Larson, C.P. &Prestwich, R. Unexpected cardiac arrest during anesthesia and surgery. J.A.M.A.236: 2758–2760 (1976).PubMedCrossRefGoogle Scholar
  9. Wylie, W.D. There, but for the grace of God ... Ann. Roy. Coll. Surg.56: 171–180 (1975).Google Scholar

Copyright information

© Canadian Anesthesiologists 1979

Authors and Affiliations

  • J. E. Utting
    • 1
  • T. C. Gray
    • 2
  • F. C. Shelley
    • 2
  1. 1.University of Liverpool. Royal Liverpool Hospital.LiverpoolEngland
  2. 2.Medical Defence UnionEngland

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