Use of medical simulation to explore equipment failures and human-machine interactions in anesthesia machine pipeline supply crossover

Anesthesia and Analgesia

Volumn 110, Issue 5, 2010, Pages 1292-1296

  Mudumbai, Seshadri C ^a,b   Fanning, Ruth ^b   Howard, Steven K ^a,b   Davies, M Frances ^b   Gaba, David M ^a,b  

^a Veterans Administration   (United States)

^b STANFORD UNIVERSITY SCHOOL OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

NITROUS OXIDE; OXYGEN;

ANESTHESIA; ANESTHETIC EQUIPMENT; ERROR; FLOWMETER; OXYGEN THERAPY; OXYGENATION; PATIENT MONITORING; PIPELINE; PRIORITY JOURNAL; REVIEW; SIMULATION; VITAL SIGN;

EID: 77951714426     PISSN: 00032999     EISSN: None     Source Type: Journal    
DOI: 10.1213/ANE.0b013e3181d7e097     Document Type: Review

References (19)

1. Elias B. Human Performance Study Report, Vertical Motion Simulator Activities, Phase I Examination: Backdrive of Accident Flight, NTSB number DCA02MA001. Washington, DC: National Transportation Safety Board, Office of Aviation Safety, October 2002
2. Brenner M. Human Performance Study Report, Vertical Motion Simulator Activities, Phase II Examination, NTSB number DCA02MA001. Washington, DC: National Transportation Safety Board, Office of Aviation Safety, June 2003
3. Tran D, Hernandez E. Use of the vertical motion simulator in support of the American Airlines flight 587 accident investigation. Proceedings of the AIAA Modeling and Simulation Technologies Conference and Exhibit, August 16-19, 2004, AIAA 2004-5032
4. Cooper JB, Taqueti VR. A brief history of the development of mannequin simulators for clinical education and training. Qual Saf Health Care 2004;13(suppl 1):i11-8
5. Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology 1984;60:34-42
6. Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: recreating the operating room for research and training. Anesthesiology 1988;69:387-394
7. Herff H, Paal P, von Goedecke A, Lindner KH, Keller C, Wenzel V. Fatal errors in nitrous oxide delivery. Anaesthesia 2007;62:1202-1206
8. ISMP. Fatal gas line mix-up: how to avoid making this "ghastly" mistake. ISMP Medication Safety Alert! Acute Care edition. December 16, 2004;9:1-2
9. Caplan RA, Vistica MF, Posner KL, Cheney FW. Adverse anesthetic outcomes arising from gas delivery equipment: a closed claims analysis. Anesthesiology 1997;87:741-748
10. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology 1990;72:828-833
11. Weller J, Merry A, Warman G, Robinson B. Anaesthetists' management of oxygen pipeline failure: room for improvement. Anaesthesia 2007;62:122-126
12. Lorraway PG, Savoldelli GL, Joo HS, Chandra DB, Chow R, Naik VN. Management of simulated oxygen supply failure: is there a gap in the curriculum? Anesth Analg 2006;102:865-867
13. United States Food and Drug Administration. Anesthesia Apparatus Checkout Recommendations. Rockville, MD: Food and Drug Administration, 1993
14. Gaba DM, Howard SK, Flanagan B, Smith BE, Fish KJ, Botney R. Assessment of clinical performance during simulated crises using both technical and behavioral ratings. Anesthesiology 1998;89:8-18
15. Eisenkraft JB. A commentary on anesthesia gas delivery equipment and adverse outcomes. Anesthesiology 1997;87:731-733
16. Dalley P, Robinson B, Weller J, Caldwell C. The use of highfidelity human patient simulation and the introduction of new anesthesia delivery systems. Anesth Analg 2004;99:1737-1741
17. Hamman W. In-situ simulation: using aviation principles to identify relevant teamwork and systems issues to promote patient safety. In: Simulation-Based Team Training for Patient Safety, FORUM, December 2008;26: No.4
18. Cook RI, Woods DD. Operating at the 'sharp end': the complexity of human error. In: Bogner MS, ed. Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum, 1994:255-310
19. Waldrop WB, Murray D J, Boulet JR, Kras JF. Management of anesthesia equipment failure: a simulation-based resident skill assessment. Anesth Analg 2009;109:426-433