Skip to main content
SpringerLink
Log in

The study of morbid events

  • Chapter
Book cover Quality of Care in Anaesthetic Practice

  • 67 Accesses

Abstract

Two patients seated outside an X-ray department were engaged in conversation. One, a hospital “regular” asked the other who was in hospital for the first time, if he was a medical or a surgical patient. Receiving a blank stare he explained helpfully, “Well, were you ill before you came to hospital or did they make you ill here?”. The story is a pointed reminder that, despite the best of intentions, patients may suffer harm.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 29.99
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  • Ahearn, R.S. (1980). Minor complications of anaesthesia. In Gray, T.C., Nunn, J.F. and Utting, J.E. (eds), General Anaesthesia, Volume 2, 4th edn, London: Butterworth, 1079–89

    Google Scholar 

  • Armitage, P. (1971). Statistical Methods in Medical Research. Oxford: Blackwell

    Google Scholar 

  • Asbury, A.J. (1981). Problems of the immediate postanaesthesia period. Br. J. Hosp. Med., 25, 159–63

    PubMed  CAS  Google Scholar 

  • Ashby, Lord E. (1978). Reconciling Man with the Environment. Oxford University Press

    Google Scholar 

  • Atkinson, R.S., Rushman, G.B. and Lee, J.A. (1982). A Synopsis of Anaesthesia, 9th edn. Bristol: Wright

    Google Scholar 

  • Barnes, P.J. and Havill, J.H. (1980). Anaesthetic complications requiring intensive care. A five year review. Anaesth. Intens. Care, 8, 404–9

    CAS  Google Scholar 

  • Boquet, G., Bushman, J.A. and Davenport, H.T. (1980). The anaesthetic machine — a study of function and design. Br. J. Anaesth., 52, 61–7

    Article  PubMed  CAS  Google Scholar 

  • Cooper, J.B., Newbower, R.S., Long, C.D. and McPeek, B. (1978). Preventable anesthesia mishaps: a study of human factors. Anesthesiology, 49, 399–406

    Article  PubMed  CAS  Google Scholar 

  • Cooper, J.B., Long, C.D., Newbower, R.S. and Phillip, J.H. (1982). Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology, 56, 456–61

    Article  PubMed  CAS  Google Scholar 

  • Couch, N.P., Tilney, N.L., Rayner, A.A. and Moore, F.D. (1981). The high cost of low frequency events. The anatomy and economics of surgical mishaps. N. Engl. J. Med., 304, 634–7

    Article  PubMed  CAS  Google Scholar 

  • Cormack, R.S. (1983) Br. J. Anaesth. (in press) Craig, J. and Wilson, M.E. (1981). A survey of anaesthetic misadventures. Anaesthesia, 36, 933–6

    Google Scholar 

  • Cronin, M., Redfern, P.A. and Utting, J.E. (1973). Psychometry and postoperative complaints in surgical patients. Br. J. Anaesth., 45, 879–86

    Article  PubMed  CAS  Google Scholar 

  • Cundy, J. and Baldock, G.J. (1982). Safety check procedures to eliminate faults in anaesthetic machines. Anaesthesia, 37, 161–9

    Article  PubMed  CAS  Google Scholar 

  • Dinnick, O.P. (1973). Hazards of respiratory circuits. Ann. Roy. Coll. Surg. Engi., 52, 349–54

    CAS  Google Scholar 

  • Feinstein, A.R. and Horwitz, R.I. (1982). Double standards, scientific methods and epidemiological research. N. Engl. J. Med., 307, 1611–7

    Article  PubMed  CAS  Google Scholar 

  • Freiman, J.A., Chalmers, T.C., Thomas, A.B., Smith, H. and Keubler, R.R., (1978). N. Engl. J. Med., 299, 690–4

    Article  PubMed  CAS  Google Scholar 

  • Gordh, T. and Mostert, J.W. (eds) (1978). Anesthetic accidents: case studies. International Anesthesiology Clinics, 16, no.3

    Google Scholar 

  • Gore, S.M. (1982). Statistics in Question. In, Lock, S.P. (ed.) Statistics in Practice. London: British Medical Association

    Google Scholar 

  • Griffon, M. (1980). A method for analysing incidents due to human errors on nuclear installations. Reliability Engineering, 1, 83–88

    Article  Google Scholar 

  • Hurter, D. (1982). Failure in pipe-line systems. Back to the cylinder? Anaesthesia, 37, 1221–2

    Article  PubMed  CAS  Google Scholar 

  • Kerr, J.H. (1982). Failure of a ventilator alarm. A reply. Anaesthesia, 37, 1044

    Article  Google Scholar 

  • Lunn, J.N. and Mushin, W.W. (1982). Mortality associated with anaesthesia. Anaesthesia, 37, 856

    Article  PubMed  CAS  Google Scholar 

  • McPeek, B. and Gilbert, J.P. (1983). Epidemiologic methods in anesthesia. In, Orkin, F.K. and Cooperman, L.H. (eds) Complications in Anesthesiology. Philadelphia: Lippincott

    Google Scholar 

  • Newbower, R.S., Cooper, J.B. and Long, C.D. (1980). Failure analysis — the human element. In Gravenstein, J.S. (ed.) Essential Noninvasive Monitoring in Anesthesia. New York: Grune and Stratton

    Google Scholar 

  • Newbower, R.S., Cooper, J.B. and Long, C.D. (1981). Learning from anesthesia mishaps. Quality Review Bulletin, 7, 10–16

    PubMed  CAS  Google Scholar 

  • Orkin, F.K. and Cooperman, L.H. (eds) (1983). Complications in Anesthesiology. Philadelphia: Lippincott

    Google Scholar 

  • Rahe, R.H. (1972). Subject’s recent life changes and their near-future illness reports. Ann. Clin. Res., 4, 250

    PubMed  CAS  Google Scholar 

  • Robinson, J.S. (1982). An appraisal of piped medical gas systems. Br. J. Hosp. Med., 28, 160–4

    PubMed  CAS  Google Scholar 

  • Roth, F. and Karmann, U. (1982). Failures in pipe-line systems. A comment. Anaesthesia, 37, 1222

    Google Scholar 

  • Rothschild, Lord N.M.V.R. (1978), The Listener, 100, 715–8

    Google Scholar 

  • Scott, D.B. (1982). Anaesthetic morbidity and mortality. Br. J. Anaesth., 54, 477

    Article  Google Scholar 

  • Shribman, A.J. (1982). Failure of a ventilator alarm. Not up to specification? Anaesthesia, 37, 1044

    Article  PubMed  CAS  Google Scholar 

  • Thompson, P.W. (1983). “Out of this nettl…” Ann. Roy. Coll. Surg. Engl., 64, 14–7

    Google Scholar 

  • Thorp, J.M. and Railton, M. (1982). Failures in pipe-line systems. A further comment and a correction. Anaesthesia, 37, 1222–3

    Article  Google Scholar 

  • Tracey, J.A., Holland, A.J.C. and Unger, L. (1982). Morbidity in minor gynaecological surgery: a comparison of halothane, enflurane and isoflurane. Br. J. Anaesth, 54, 1213–5

    Article  PubMed  CAS  Google Scholar 

  • Tunstall, M.E. (1980). Chapter 71. In Gray, T.C. and Utting, J.E. (eds). General Anaesthesia, Volume 2, 4th edn. London: Butterworth, 1367–90

    Google Scholar 

  • Utting, J.E., Gray, T.C. and Shelley, F.C. (1979). Human misadventure in anaesthesia. Can. Anaesth. Soc. J., 26, 472–8

    Article  PubMed  CAS  Google Scholar 

  • Vaughan, R.W. and Vaughan, M.S. (1982). Anesthetic related complications: prospective model to identify perioperative risks. Anesthesiology, 57, A93

    Article  Google Scholar 

  • Wilson, M.E. and Burleton, A.S. (1982). Leak tests. Br. J. Anaesth., 54, 572

    Article  PubMed  CAS  Google Scholar 

  • Wyant, G.M. (1978). Mechanical Misadventures in Anaesthesia. University of Toronto Press

    Google Scholar 

  • Wylie, W.D. (1975). “There, but for the grace of God…”. Ann. Roy. Coll. Surg. Engl., 56, 171–80

    CAS  Google Scholar 

  • Wylie, W.D. (1981). Editorial, Safer Anaesthesia. Anaesthesia, 36, 357

    Article  Google Scholar 

  • Young, D.W. (1982). A survey of decision aids for clinicians. Br. Med. J., 285, 1332–6

    Article  CAS  Google Scholar 

Download references

Authors
  1. M. E. Wilson
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Welsh National School of Medicine, Cardiff, UK

    John N. Lunn MD, FFARCS (Reader in Anaesthetics) (Reader in Anaesthetics)

Copyright information

© 1984 The Royal Society of Medicine

About this chapter

Cite this chapter

Wilson, M.E. (1984). The study of morbid events. In: Lunn, J.N. (eds) Quality of Care in Anaesthetic Practice. Palgrave Macmillan, London. https://doi.org/10.1007/978-1-349-06907-1_5

Download citation

  • DOI: https://doi.org/10.1007/978-1-349-06907-1_5

  • Publisher Name: Palgrave Macmillan, London

  • Print ISBN: 978-0-333-35814-6

  • Online ISBN: 978-1-349-06907-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation