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Canadian Journal of Anaesthesia

, Volume 39, Issue 2, pp 118–122 | Cite as

Accident analysis of large-scale technological disasters applied to an anaesthetic complication

  • Chris J. Eagle
  • Jan M. Davies
  • J. Reason
Reports of Investigation

Abstract

The occurrence of serious accidents in complex industrial systems such as at Three Mile Island and Bhopal has prompted development of new models of causation and investigation of disasters. These analytical models have potential relevance in anaesthesia. We therefore applied one of the previously described systems to the investigation of an anaesthetic accident. The model chosen describes two kinds of failures, both of which must be sought. The first group, active failures, consists of mistakes made by practitioners in the provision of care. The second group, latent failures, represents flaws in the administrative and productive system. The model emphasizes the search for latent failures and shows that prevention of active failures alone is insufficient to avoid further accidents if latent failures persist unchanged. These key features and the utility of this model are illustrated by application to a case of aspiration of gastric contents. While four active failures were recognized, an equal number of latent failures also became apparent. The identification of both types of failures permitted the formulation of recommendations to avoid further occurrences. Thus this model of accident causation can provide a useful mechanism to investigate and possibly prevent anaesthetic accidents.

Key words

complications: accidents 

Résumé

La survenue d’une série d’accidents dans des complexes industriels tels que Three Mile Island et Bhopal ont déclenché le développement de nouvelles méthodes de causalité et d’investigation de désastres. Ces modèles analytiques sont potentiellement intéressants en anesthésie. Ainsi, on a appliqué un des systèmes préalablement décrits afin d’étudier les accidents anesthésiques. Le modèle choisi décrit deux sortes d’échecs qui doivent tous les deux être recherchés. Le premier groupe, des échecs actifs, consiste en des erreurs que le practicien commet dans la pratique de sa profession. Le deuxième groupe, des échecs latents, représente des défauts dans les sytèmes administratifs et productifs. Le modèle met l’emphase sur la recherche des échecs latents et démontre que la prévention des échecs actifs seul n’est pas suffisant afin d’éviter des accidents futurs si les échecs latents demeurent inchangés. Ces critères de base et l’utilité de ce modèle sont illustrés par l’application dans un cas d’aspiration du contenu gastrique. Alors que quatre échecs actives furent reconnus, un nombre égal d’échecs latents est devenu apparent. L’identification des deux types d’échecs permet la formulation de recommandations afin d’éviter la répétition de ces échecs. Ainsi, ce modèle d’investigation des causalités d’accidents peut fournir un mécanisme utile d’investigation et possiblement de prévention des accidents anesthésiques.

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Copyright information

© Canadian Anesthesiologists 1992

Authors and Affiliations

  • Chris J. Eagle
    • 1
  • Jan M. Davies
    • 1
  • J. Reason
    • 2
  1. 1.Department of AnaesthesiaFoothills Hospital at the University of CalgaryCalgaryCanada
  2. 2.Department of PsychologyUniversity of ManchesterManchesterUK

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