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Author(s) -
Heath Margaret L.
Publication year - 1984
Publication title -
anaesthesia
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.839
H-Index - 117
eISSN - 1365-2044
pISSN - 0003-2409
DOI - 10.1111/j.1365-2044.1984.tb09458.x
Subject(s) - medicine , medical emergency , risk analysis (engineering)
Summary Serious accidents in which the possibility of equipment‐related hazards are raised have been reported to the Scientific and Technical Branch of the Department of Health and Social Security. The author has examined anonymous summaries of 23 such reports of events which occurred over a 5‐year period. The principle cause of catastrophe in seventeen of the incidents was user error involving disconnexion or misconnexion. Faulty systems of equipment management combined in some cases with inadequate pre‐anaesthetic checking of apparatus were responsible for the other instances. Appropriate systems of equipment management and checking together with meticulous basic clinical monitoring are recommended as the best safeguards in anaesthetic practice.