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Anesth Essays Res. 2019 Apr-Jun;13(2):193-198. doi: 10.4103/aer.AER_47_19.

Root Cause Analysis of Blunders in Anesthesia.

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Department of Anesthesia and Intensive Care, Faculty of Medicine, Menoufia University, Menoufia, Egypt.
Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt.


The frequency of blunders perioperative because of anesthesia is expanding, and the precise occurrence is significantly thought little of practically due to underreporting. Root cause analysis of majority of anesthesia errors due to lack of knowledge, unfollow the patient procedures and guidelines, medications errors and lack of communication between the members of anesthesia team leading to morbidity or even mortality. The cornerstone in the operating room environment is the communication, especially the patient's data are accumulated and changed continuously during a patient's anesthesia. Continuous attempts for establishing Iideal strategies to reduce the incidence and chance of anesthesia errors. The advancement of a nonaccuse condition where mistakes are transparently revealed and talked about, and guidelines for naming the medication holders, vials, and ampoules are focused. All endeavors ought to be made in the revealing and anticipation of medical drug errors. It is time to incorporate electronic and digital concepts to encourage the evolution of anesthesia-related drug delivery system.


Analysis; anesthesia; blunders; cause; root

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