Human Error in Anesthesia

The occurrence of human errors in anesthesia has become an important issue because in recent years many anesthesia-related deaths are considered to be the result of human error. A study of 589 anesthesia-related deaths revealed that human error was an important factor in 83% of the cases [7,8]. Additional facts and figures directly or indirectly concerned with human error in anesthesia are available in Ref. [2]. 

Inadvertent change in gas flow Breathing circuit misconnection Ventilator failure Ampule swap 

Breathing circuit disconnection Hypoventilation (operator error) 

Premature extubation Endobronchial intubation Breathing circuit leak Unintentional extubation 

Additionally, some of the common causes of anesthesia errors are carelessness, haste and fatigue, emergency case, poor familiarity with anesthetic method, inadequate anesthesia-related experience, lack of skilled assistance or supervision, excessive reliance on other persoimel, failure to carry out a proper examination, visual field restriction, poor familiarity with equip-ment/device, teaching activity in progress, and poor communication with the surgical team or the laboratory personnel [10]. 

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