Preventable anesthesia-related adverse events at a large tertiary care center: a nine-year retrospective analysis.
Anesthesiologists have pioneered techniques like human factors engineering in an effort to achieve high reliability in perioperative care. Researchers examined 747 adverse anesthesia events at a single institution and found that 43% were preventable. Most preventable events were either respiratory complications or patient injuries, and they were largely due to systems issues rather than individual clinician performance.
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