Anesthesia: Essays and Researches  Login  | Users Online: 1714 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size
Home | About us | Editorial board | Ahead of print | Search | Current Issue | Archives | Submit article | Instructions | Copyright form | Subscribe | Advertise | Contacts

Table of Contents  
Year : 2019  |  Volume : 13  |  Issue : 2  |  Page : 193-198  

Root cause analysis of blunders in anesthesia

1 Department of Anesthesia and Intensive Care, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Web Publication28-May-2019

Correspondence Address:
Ayman Aly Rayan
Department of Anesthesia and Intensive Care, Faculty of Medicine, Menoufia University, Menoufia
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aer.AER_47_19

Rights and Permissions

The frequency of blunders perioperative because of anesthesia is expanding, and the precise occurrence is significantly thought little of practically due to underreporting. Root cause analysis of majority of anesthesia errors due to lack of knowledge, unfollow the patient procedures and guidelines, medications errors and lack of communication between the members of anesthesia team leading to morbidity or even mortality. The cornerstone in the operating room environment is the communication, especially the patient's data are accumulated and changed continuously during a patient's anesthesia. Continuous attempts for establishing Iideal strategies to reduce the incidence and chance of anesthesia errors. The advancement of a nonaccuse condition where mistakes are transparently revealed and talked about, and guidelines for naming the medication holders, vials, and ampoules are focused. All endeavors ought to be made in the revealing and anticipation of medical drug errors. It is time to incorporate electronic and digital concepts to encourage the evolution of anesthesia-related drug delivery system.

Keywords: Analysis, anesthesia, cause, blunders, root

How to cite this article:
Rayan AA, Hemdan SE, Shetaia AM. Root cause analysis of blunders in anesthesia. Anesth Essays Res 2019;13:193-8

How to cite this URL:
Rayan AA, Hemdan SE, Shetaia AM. Root cause analysis of blunders in anesthesia. Anesth Essays Res [serial online] 2019 [cited 2020 Sep 28];13:193-8. Available from:

   Introduction Top

The press and public are unforgiving of those perceived to have harmed patients as a result of seemingly basic mistakes, inattention or carelessness, and equate such mistakes with medical negligence. More than half of the public believe that suspending doctors who have committed clinical errors is an effective prevention strategy.[1]

Throughout the previous 20 years, there was an expanding center around the issue of medicinal blunders made by specialists, attendants, and paramedical staff in clinics. The report by the Institute of Medicine (IOM) in the USA, titled “To Err is Human,” evaluated that between 44,000 and 98,000 hospitalized patients bite the dust every year in the USA because of medical blunders.[2] The genuine issue was not the way to prevent terrible doctors from hurting or executing their patients; however, how to keep the great doctors from doing as such.[3]

An anesthesiologist injects around half a million different drugs in his/her professional tenure as well as with unpredictable physiological responses of anesthetized patients would not display or verbalize any symptoms that an awake patient would, such as bronchospasm, hypotension, arrhythmias, or cardiac arrest. In 2000, a report in the United Kingdom reported that medical errors caused harm (death or injury) to more than 850,000 patients admitted to National Health Service Hospitals annually.[4]

   Incidence Top

Bates et al. found 2 of every 100 inpatients experience a preventable adverse drug event, resulting in an average increase of hospital costs by $4700 per admission almost about $2.8 million annually in a 700-bed hospital.[5] The Australian Healthcare Study found adverse events (unintended injury or complication caused by health-care provider) occurred in 16.6% of hospital admissions, with 51% of these adverse events judged to be “highly preventable” as well as death incidence was around 4.9% of patients suffering an adverse event, and permanent disability in 13.7%.[6]

Webster et al.[7] performed a study on 7794 anesthesiologist responses in two hospitals; they found the frequency of drug administration error per anesthetic case was 0.0075% with the two largest categories of errors involving incorrect doses (20%) and substitutions (20%), concluding adverse drug effects (ADE) during anesthesia.

Sakaguchi et al. reported the incidence of anesthesia-related medication errors in a university hospital in Japan through 15 years and based on 64,285 anesthesia cases concluded drug errors happened in only 50 cases (0.078%) much lower from earlier reported incidence.[8] The most common types of medications associted with the incidence of errors are opioids, cardiac supports, and vasopressors; and interestingly, the responsible anesthesiologists commonly were doctors with little experience. In South Africa, Llewellyn et al.[9] reported an incidence of 0.37% incidences for 30,412 anesthetics with a conclusion that neither the experience of the anesthetist nor the emergent nature of the surgery influenced the incidence and nearly 40% of all blunders occurred due to misidentification of drug ampoules. No major complication attributable to ADE was reported. Cooper et al.[10] also found the rate of medication error during anesthesia of 0.49% (52 errors from 10,574 case forms or 1/203 anesthetics) and a two-fold increase in the rates by anesthesia-in-training providers compared to an expert doctor, most commonly due to incorrect dose and drug substitution.

Zhang et al.[11] in a prospective study in China reported a medication error rate about 0.73% (179 errors during 16,496 anesthetics), the largest category being an omission, incorrect dosage, and substitutions, collectively accounting for >65% of all errors. These led to serious complications in at least two and inadvertent intensive care admissions for five patients. When combining the three prospective study findings of Webster et al.,[7] Llewellyn et al.,[9] and Cooper et al.,[10] 244 errors were reported on 51,504 administered anesthetics. That gave us a combined incidence of 1 in 211 medication errors in anesthesia practice.[12] Based on a limited number of prospective studies, the incidence of medication error in anesthetic practice ranges from 0.33% to 0.73%, and shockingly, this rate has not changed over the last 15 years.[8]

   Root Cause Analysis Top

Root cause no 1 (the complexity nature of anesthesia work)

Anesthesiologists work in a complex, rapidly changed, and stressful work environment where effective performance demands expert knowledge, appropriate problem-solving strategies, and fine motor skills. Safe anesthesia administration requires vigilance (e.g., detection of changes in patient condition),[13] time-sharing among multiple tasks and the ability to rapidly make decisions and take actions.[14] The anesthesiologist primary goals include protecting the patient from harm and facilitating surgery. Intraoperative anesthesia care is divided into induction, maintenance, and emergence.[15]

Root cause no 2 (lack of communication)

The foundation in the operating room environment is the communication, especially the patient's data are accumulated and changed constantly during a patient's anesthesia.

An analysis of over 2400 events reported due to lack of effective communication was the primary issue involved in 70% of the events and 75% of these patients died [Table 1].[16],[17]
Table 1: Types of system errors

Click here to view

The Joint Commission on Accreditation of Healthcare Organizations identified breakdowns in communication is considered the leading root cause of wrong-site operations.[18] Communication is poor in surgery rises to 32%, 38% in anesthesia and surgery, and 50% between anesthesia and surgery.[19] Further obstacles such as fearing from judgment of others, or uncertainty “I am not sure I am right” can make communication even more complex leading to inhibition health-care workers from effective speaking to each other. Proper assertions are mandatory for transmitting data; whereas, indirect communication is prone to failure. Authoritative leaders may create an artificial gap around themselves suppressing upstream communications reaching them. Communicative leaders create a familiar and friendly atmosphere that allows members of the team to express their concerns. Effective communication will not avoid errors in health care but at least reduce the probability of an error will have operational consequences and decrease the possibility of injuring or killing a patient.[20] Anesthesiologists and surgeons usually speak in different terms when discussing cases. Part of the disconnect is that surgeons deal with a diagnosis requiring surgical intervention, while anesthesiologists deliver anesthesia to facilitate a surgery while simultaneously keeping risky patients organs viable.[21] The safety of anesthesia improved by an understanding of anesthetic-related deaths, the advent of better monitoring practices, improved airway management tools, sharing of safety knowledge, and peer review [Table 2].[22]
Table 2: Negligence identified by peer review

Click here to view

Root cause no 3 (negligence)

The classification was designed to describe each incident, including all circumstances that may have contributed to the occurrence. Not all information could be obtained for each incident. Each of the 23 major categories of the classification included multiple branches for the observed varieties of data [Table 3] and [Table 4].[23]
Table 3: 23 major categories of information collected for each critical incident

Click here to view
Table 4: The most frequent incidents

Click here to view

Root cause no 4 (human-related errors)

Cooper et al. published their study about human errors as more common than equipment failure in preventable incidents, which was the first time such errors were reported systematically in the anesthesia literature.[24] On the other hand, Frederick and Cheney found that 82% of incidents were inadvertent mistakes such as “syringe swaps,” accidental changes in fresh gas flow, or unfamiliarity with equipment.[25] Initially the mechanics of medication delivery such as the use of color-coded syringe labels and barcoding of pharmaceuticals, patients, and labels as a standard measures to decrease the incidence of medications blunders. Meanwhile, both nursing and pharmacy studies looked at using two practitioners to read labels and orders.[26],[27] Anesthesia published a retrospective analysis titled “A survey of anesthetic misadventures” in which >8000 incident reports in a busy hospital were analyzed, finding that most incidents arose out of failure to perform a normal check, both with medications and equipment.[28] A retrospective analysis published in 1990 covered >113,000 accident reports during a 10-year period. The so inattention, failure to check, lack of vigilance, and carelessness were identified as factors[29] [Table 5].[22]
Table 5: Types of human errors

Click here to view

Root cause no 5 (errors due to medications administration)

Drug mistakes in the Closed Claims Audit showed about 24% result in a fatality, while newer anesthetic medications are safer than before; drug errors in anesthesia occur relatively frequently. Most medication errors are ultimately benign; however, a subset results in significant harm or escalation in care. Consequently, vigilance plays a role in avoiding anesthetic mishaps in all cases.[10],[30]

The topic of medication-related errors is popular in the medical literature because such errors comprise the most common error in the medical profession, preventable medication errors result in >7000 deaths each year in hospitals alone and tens of thousands more in outpatient facilities. Bates et al.[5] reported that nearly 30% of patient injuries occurring in a teaching hospital resulted from preventable ADE's. Estimated excess hospital costs attributable per ADE were $4700 in a year. Based on this estimate, they calculated the cost related to preventable ADE's to be about $2.8 million per year for a 700-bed hospital. According to this data, the cost of preventable ADE's would extrapolate to about $2 billion across the nation's hospitals [Table 6].[21],[31]
Table 6: Stages of medication administration

Click here to view

Classen et al.[32] reported that 2.4 ADE's occurred per 100 hospitals admissions and estimated that about 50% of these events were preventable. Lesar et al.[33] determined that approximately 3.99 prescription errors per 100 medications ordered. Edmondson[34] reported that 0.35% of 80,000 patients in New York State hospitals suffer a disabling injury caused by medication during hospitalization. She also stated that there is an average of 1.4 medication errors per patient per stay; of these errors, 0.9% leads to serious drug complications. In the Harvard Medical practice study,[35] ADE's accounted for 19% of injuries to hospitalized patients and represented the single most common cause of injury [Table 7].[36]
Table 7: Causes of medication administration blunders in hospitals

Click here to view

   Examples of Reported Incidents and Medication Errors Top

Common medication errors in anesthesia include drug swaps (thiopentone in place of antibiotics, suxamethonium in place of fentanyl or syntocinon); duplication of drugs or errors of drug dosage, particularly opioids or paracetamol in children. Residual anesthetic drugs in the IV line have devastating consequences patient had an appendectomy. On coming back to the ward had intravenous with short extension flushed with saline. Shortly after had a cardiac arrest thought that residual muscle relaxant in the line caused a respiratory arrest pursued by a cardiac arrest.

   Consequences of Medication Errors Top

Medication errors are an important cause of patient morbidity and mortality.[37] Although only 10% of medication errors due to ADE, these errors have profound implications for patients, families, and health-care providers.[38] The IOM reported 44,000–98,000 patients to die each year as a result of medical errors most of these being medication-related. Around 19% of medication errors in the intensive care unit are life-threatening and 42% are of sufficient clinical importance to warrant additional life-sustaining treatments. The human and societal burden is even greater with many patients experiencing costly and prolonged hospital stays and some patients never fully recovering to their premorbidity status.[32]

Bates et al.[5] estimated that in American hospitals, the annual cost of serious medication errors in 1995 was $2.9 million per hospital and that a 17% decrease in incidence would result in $480,000 savings per hospital. Finally, the psychological impact of errors should not be ignored.[5]

Errors erode patient, family, and public confidence in health-care organizations.[39] Memories of errors can haunt providers for a long time[40] [Table 8].[31]
Table 8: Severity of medication error

Click here to view

   Conclusions and Recommendations Top

  • Anesthesia blunders range from no harm up to death, while there are patients complain from sustained significant injury leading to long-term harm or death as a sequence of bad results likely damage public confidence in health-care professionals who suffer from a damaged reputation, lack of confidence, and charges of negligence
  • No anesthesiologist intentionally executes a mistake, but errors are unforgiving that they can cost up to human life. In an era where patients' knowledge and awareness about diseases and their management is expanding, clinicians need to be more vigilant to avoid unfortunate outcomes and medicolegal claims
  • All efforts should be made in the reporting and prevention of medical drug blunders. It is time to incorporate electronic and digital concepts to encourage the evolution of anesthesia-related drug delivery system. We infer that “to err may be human, but in health care, to err repeatedly is foolish and maybe criminal”
  • Systems need to be engineered to reduce the likelihood of medications misidentification through approaches such as revision of standards for labeling of drug ampoules and vials and the development of advanced electronic/digital mechanisms that allow “double-checking.”[41] The contribution of the practice of anesthesia to the global problem of medication error is far from clear and very difficult to study. Efforts rely on incident reporting, the only practical approach when funding is limited, and routine anesthesia is so safe. Efforts have begun to reduce medication error without waiting for the problem to happen
  • In evidence-based medicine, anesthetists are looking for solutions to the problems that we may have to accept good practical reasons. Medication errors usually result from a failure of a system as well as individual.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, et al. Views of practicing physicians and the public on medical errors. N Engl J Med 2002;347:1933-40.  Back to cited text no. 1
Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, National Academy Press; 1999.  Back to cited text no. 2
Gawande A. When doctors make mistakes. The New Yorker; 1 February, 1999. p. 40-55.  Back to cited text no. 3
Brennan TA. The institute of medicine report on medical errors – Could it do harm? N Engl J Med 2000;342:1123-5.  Back to cited text no. 4
Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 1997;277:307-11.  Back to cited text no. 5
Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The quality in Australian health care study. Med J Aust 1995;163:458-71.  Back to cited text no. 6
Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care 2001;29:494-500.  Back to cited text no. 7
Sakaguchi Y, Tokuda K, Yamaguchi K, Irita K. Incidence of anesthesia-related medication errors over a 15-year period in a university hospital. Fukuoka Igaku Zasshi 2008;99:58-66.  Back to cited text no. 8
Llewellyn RL, Gordon PC, Wheatcroft D, Lines D, Reed A, Butt AD, et al. Drug administration errors: A prospective survey from three South African teaching hospitals. Anaesth Intensive Care 2009;37:93-8.  Back to cited text no. 9
Cooper L, DiGiovanni N, Schultz L, Taylor AM, Nossaman B. Influences observed on incidence and reporting of medication errors in anesthesia. Can J Anaesth 2012;59:562-70.  Back to cited text no. 10
Zhang Y, Dong YJ, Webster CS, Ding XD, Liu XY, Chen WM, et al. The frequency and nature of drug administration error during anaesthesia in a Chinese hospital. Acta Anaesthesiol Scand 2013;57:158-64.  Back to cited text no. 11
Cooper L, Nossaman B. Medication errors in anesthesia: A review. Int Anesthesiol Clin 2013;51:1-2.  Back to cited text no. 12
Gaba DM, Howard SK, Small SD. Situation awareness in anesthesiology. Hum Factors 1995;37:20-31.  Back to cited text no. 13
Gaba DM, Fish KJ, Howard SK. Crisis Management in Anesthesiology. New York: Churchill Livingstone; 1994.  Back to cited text no. 14
Weinger MB, Englund CE. Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. Anesthesiology 1990;73:995-1021.  Back to cited text no. 15
Leonard M, Graham S, Bonacum D. The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13 Suppl 1:i85-90.  Back to cited text no. 16
Morray JP, Geiduschek JM, Ramamoorthy C, Haberkern CM, Hackel A, Caplan RA, et al. Anesthesia-related cardiac arrest in children: Initial findings of the pediatric perioperative cardiac arrest (POCA) registry. Anesthesiology 2000;93:6-14.  Back to cited text no. 17
Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: Cross sectional surveys. BMJ 2000;320:745-9.  Back to cited text no. 18
Li G, Warner M, Lang BH, Huang L, Sun LS. Epidemiology of anesthesia-related mortality in the United States, 1999-2005. Anesthesiology 2009;110:759-65.  Back to cited text no. 19
Bracco D, Favre JB, Bissonnette B, Wasserfallen JB, Revelly JP, Ravussin P, et al. Human errors in a multidisciplinary intensive care unit: A 1-year prospective study. Intensive Care Med 2001;27:137-45.  Back to cited text no. 20
Beecher HK, Todd DP. A study of the deaths associated with anesthesia and surgery: Based on a study of 599, 548 anesthesias in ten institutions 1948-1952, inclusive. Ann Surg 1954;140:2-35.  Back to cited text no. 21
Edbril SD, Lagasse RS. Relationship between malpractice litigation and human errors. Anesthesiology 1999;91:848-55.  Back to cited text no. 22
Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: A study of human factors 1978. Qual Saf Health Care 2002;11:277-82.  Back to cited text no. 23
Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: A study of human factors. Anesthesiology 1978;49:399-406.  Back to cited text no. 24
Cheney FW. The American Society of Anesthesiologists closed claims project: The beginning. Anesthesiology 2010;113:957-60.  Back to cited text no. 25
Claeys RW, Decamp GS. U.S. Patent No. 4,853,521. Washington, DC: U.S. Patent and Trademark Office; 1989.  Back to cited text no. 26
O'Shea E. Factors contributing to medication errors: A literature review. J Clin Nurs 1999;8:496-504.  Back to cited text no. 27
Craig J, Wilson ME. A survey of anaesthetic misadventures. Anaesthesia 1981;36:933-6.  Back to cited text no. 28
Chopra V, Bovill JG, Spierdijk J. Accidents, near accidents and complications during anaesthesia. A retrospective analysis of a 10-year period in a teaching hospital. Anaesthesia 1990;45:3-6.  Back to cited text no. 29
Bowdle TA. Drug administration errors from the ASA closed claims project. ASA News 2003;67:11-3.  Back to cited text no. 30
Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology 2016;124:25-34.  Back to cited text no. 31
Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA 1997;277:301-6.  Back to cited text no. 32
Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997;277:312-7.  Back to cited text no. 33
Edmonson AC. Learning from a mistake is easier said than done: Group and organizational influences on the detection and correction of human errors. J Appl Behav Sci 1996;32:5-28.  Back to cited text no. 34
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard medical practice study I. N Engl J Med 1991;324:370-6.  Back to cited text no. 35
Keers RN, Williams SD, Cooke J, Ashcroft DM. Causes of medication administration errors in hospitals: A systematic review of quantitative and qualitative evidence. Drug Saf 2013;36:1045-67.  Back to cited text no. 36
Hussain E, Kao E. Medication safety and transfusion errors in the ICU and beyond. Crit Care Clin 2005;21:91-110, ix.  Back to cited text no. 37
Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med 2002;162:1897-903.  Back to cited text no. 38
Cohen H, Mandrack MM. Application of the 80/20 rule in safeguarding the use of high-alert medications. Crit Care Nurs Clin North Am 2002;14:369-74.  Back to cited text no. 39
Christensen JF, Levinson W, Dunn PM. The heart of darkness: The impact of perceived mistakes on physicians. J Gen Intern Med 1992;7:424-31.  Back to cited text no. 40
Orser BA, Hyland S, David U, Sheppard I, Wilson CR. Review article: Improving drug safety for patients undergoing anesthesia and surgery. Can J Anaesth 2013;60:127-35.  Back to cited text no. 41


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
   Root Cause Analysis
    Examples of Repo...
    Consequences of ...
    Conclusions and ...
    Article Tables

 Article Access Statistics
    PDF Downloaded124    
    Comments [Add]    

Recommend this journal