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• W1496395973 abstract "Health care is not as safe as it should be. Near-miss analysis may offer insight into the multiple causes of incidents and the factors that stopped progression towards adverse events. The applicability of the PRISMA (Prevention and Recovery Information System for Monitoring and Analysis) root-cause taxonomy of failure- and recovery factors on near misses in anesthesia was explored. Barriers for reporting were explored subsequently with a questionaire because of the less than expected number of reports. Members of the workinggroup on complication registration of the NVA (Dutch Society of Anesthesiology) and their associates reported near miss events in anesthesia. PRISMA was applicable to near-miss incidents in anesthesia. Most incidents had a multifactorial origin. Human factors accounted for three-quarters of failure factors and for half of recovery factors. In half the number of incidents only one recovery factor could be identified. In most cases planned human interference stopped progression towards adverse events. In one-quarter of reports the patients themselves absorbed an error unexpectedly. In a subsequent study, a questionaire was given to all participants of the yearly Dutch Anesthesiology Meeting to explore barriers to reporting. There was only a small number of respondents, but these were willing to report to improve quality of care and to learn from errors. They don't see an advantage in reporting near misses. Efforts to improve safety in anesthesia should be directed at removing barriers for reporting, application of human factors knowledge and introducing a near-miss reporting system." @default.
• W1496395973 created "2016-06-24" @default.
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• W1496395973 date "2005-09-29" @default.
• W1496395973 modified "2023-09-23" @default.
• W1496395973 title "The use of human factors and risk analysis in anesthesia in the Netherlands" @default.
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• W1496395973 doi "https://doi.org/10.5555/1124666.1124695" @default.
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