Learning from Incident Reporting and Closed Claims Analyses

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


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.


Obstructive Sleep Apnea Laryngeal Mask Airway Critical Incident Difficult Airway Failed Extubation 
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.



Anesthesia incident reporting system


American Society of Anesthesiologists


Critical incident reporting


Liters per minute


Monitored anesthesia care


National Anesthesia Clinical Outcomes Registry




Operating room


Obstructive sleep apnea


Postanesthesia care unit


Root cause analysis


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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