Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned. | AHRQ Patient Safety Network

Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned. | AHRQ Patient Safety Network

• Study
 
• Published June 2017

Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned.

Neily J, Silla ES, Sum-Ping SJT, et al. Anesth Analg. 2018;126:471-477.

This study examined root cause analyses performed by the Veterans Health Administration to identify and characterize anesthesia-related safety events. Although a relatively small number of events were found, the authors identified several human factors solutions that, if implemented, could prevent common types of errors.

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