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Epidemiol Prev. 1997 Jan-Mar;21(1):19-29.

[Human error in the anesthesiological field. Up to what point is it possible to speak of prevention?].

[Article in Italian]

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  • 1Servizio di Epidemiologia, Clinica e Biometria, I.R.C.C.S. Policlinico S. Matteo, Pavia.


Human error (the act of judging true what is false and false what is true) has ever played and plays a significant role in the occurrence of incidents during anaesthesia. Purpose of the study. The Authors wanted to study how the different Authors analyzed the problem and to outline indications for preventive measures. Materials and methods. For this purpose we have selected papers and their references published on Journals indexed on Index. Medicus (1966-1996). The key words have been: anaesthesia or anesthesia, human error, incident and critical incident. We analyzed papers where human error in anaesthesia as a source of accidents was the main topic. The problem is analyzed starting from a classification of different errors and quantified with proper cognitive methods. Finally preventive measures are proposed. Results, Contribution of human error to the occurrence of accidents in anaesthesia ranges from 37% to 87% according to different. Authors employed techniques and sample size. Proper corrective measures on human, instrumental and environmental factors can lead to increased prevention. Conclusions. Human error exists now and will ever exist. Its gravity depends on its consequences and on preventive measures adopted.

[PubMed - indexed for MEDLINE]
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