Book contents
- Frontmatter
- Contents
- List of contributors
- Preface
- 1 The role of cardiopulmonary exercise testing in preoperative evaluation of surgical patients
- 2 Oesophagectomy for cancer
- 3 Vascular surgery
- 4 Anaesthesia for the elderly
- 5 Deaths following anaesthesia: lessons from NCEPOD
- 6 Pelvic and acetabular trauma
- 7 Echocardiography
- 8 Levosimendan
- 9 Critical care outreach: 6 years on
- 10 Critical care and biological disasters: lessons learned from SARS and pandemic influenza planning
- 11 Evaluating clinical performance
- 12 Non-technical skills and anaesthesia
- 13 Simulators in anaesthetic training to enhance patient safety
- Index
- References
12 - Non-technical skills and anaesthesia
Published online by Cambridge University Press: 15 December 2009
By
Book contents
- Frontmatter
- Contents
- List of contributors
- Preface
- 1 The role of cardiopulmonary exercise testing in preoperative evaluation of surgical patients
- 2 Oesophagectomy for cancer
- 3 Vascular surgery
- 4 Anaesthesia for the elderly
- 5 Deaths following anaesthesia: lessons from NCEPOD
- 6 Pelvic and acetabular trauma
- 7 Echocardiography
- 8 Levosimendan
- 9 Critical care outreach: 6 years on
- 10 Critical care and biological disasters: lessons learned from SARS and pandemic influenza planning
- 11 Evaluating clinical performance
- 12 Non-technical skills and anaesthesia
- 13 Simulators in anaesthetic training to enhance patient safety
- Index
- References
Summary
In 2000 the UK Department of Health published a report entitled ‘An Organisation with a Memory’. This report defined an adverse health care event as ‘an event or omission arising during clinical care and causing physical or psychological injury to a patient’, and a healthcare near miss as a situation where the events/omissions or sequences of these don't develop further (owing to compensating action or good fortune). Like the earlier US Institute of Medicine report ‘To Err is Human’, this report acknowledged that it was not possible to eliminate adverse events from healthcare, but that the system should learn from past experience.
There were several recommendations designed to minimise avoidable harm to patients made in the UK report. One of these recommendations was that the experiences of other industries associated with high risk should be examined and, where appropriate, adopted by the National Health Service. The industries being referred to here have been called high-reliability organisations; that is organisations that regard safety concerns as paramount. Civil aviation, offshore oil exploration and nuclear power industries have all been categorised in this way. In these industries it has been established by means of human factors research that, rather than technical performance, human performance is highly significant in the generation and the recovery from adverse events. Human factors is the scientific discipline that is concerned with the interactions between human beings and the environment or system in which they work.
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- Recent Advances in Anaesthesia and Intensive Care , pp. 197 - 212Publisher: Cambridge University PressPrint publication year: 2007
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