Learning from Incident Reporting and Closed Claims Analyses

  • Julia Metzner
  • Karen L. Posner
  • Karen B. Domino
Chapter

Abstract

Understanding the various causes behind medical errors is key to improving patient safety. Reporting and analysis of near-miss events and adverse outcomes yields valuable information about system failures behind the incident and may lead to system redesign in order to prevent reoccurrence. The root cause analysis is a systematic approach to analyze adverse events and critical incidents. The root cause analysis analyzes what happened, how it happened, why it happened, and what can be done to prevent it from happening again. Through these steps, systems failures resulting in active and latent errors, such as human performance factors, organizational factors, and team communication issues are identified and systems are redesigned. This chapter illustrates the application of the root cause analysis using cases from the Closed Claims Database, including facial burns from an electrocautery-induced operating room fire and death from failed extubation of a difficult airway.

Keywords

Obesity Catheter Depression Leukemia Assure 

Abbreviations

AIRS

Anesthesia incident reporting system

ASA

American Society of Anesthesiologists

CIR

Critical incident reporting

L/min

Liters per minute

MAC

Monitored anesthesia care

NACOR

National Anesthesia Clinical Outcomes Registry

O2

Oxygen

OR

Operating room

OSA

Obstructive sleep apnea

PACU

Postanesthesia care unit

RCA

Root cause analysis

TOF

Train of four

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Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Julia Metzner
    • 1
  • Karen L. Posner
    • 1
  • Karen B. Domino
    • 1
  1. 1.Department of Anesthesiology and Pain MedicineUniversity of WashingtonSeattleUSA

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