Human factors in pediatric anesthesia incidents

Background: Anesthesia and the operating theater environment is a complex system involving man–machine and human–human interactions. Although we strive for an error free system, we are humans and errors and mistakes will occur. The aim of this study was to investigate the human factors behind events and incidents in pediatric anesthesia at our institution.

Methods: This study consisted of a retrospective review and analysis of all contemporaneously reported anesthetic incidents between April 1, 2002 and March 31, 2004 at Birmingham Children's Hospital. Where there were anesthetic human factors involved in the event these were classified.

Results: There were 668 incidents reported, giving a rate of 2.4% of the 28 023 anesthetics recorded. Airway and respiratory incidents were the most common representing 52.2% of all incidents. A total of 284 anesthetic human factors could be identified and classified. Of these the most common were errors in judgment 43%, failure to check 17.8%, technical failures of skill 9.2%, inexperience 7.7%, inattention/distraction 5.6% and communication issues 5.6%.

Conclusions: In our institution anesthetic human factors occur in 42.5% of in-theater incidents in pediatric anesthesia. Knowledge of these is necessary so that changes can be made in practice both by individuals and departments of anesthesia, to make anesthesia as safe as possible.