Preface, ix

Acknowledgments, xi

Introduction, xiii

1 Errors: Terminology and Background, 1

Error: terminology, 1

Conclusion, 5

References, 5

2 Errors: Organizations, Individuals, and Unsafe Acts, 7

Error causation: technical factors, 7

Error causation: organizational and supervision factors, 7

Error causation: environmental factors, 12

Error causation: personnel factors, 12

Error causation: human factors, 12

Error causation: other factors, 22

Conclusion, 22

References, 22

3 Reporting and Analyzing Patient Safety Incidents, 25

The limitation in only counting errors, 25

How can we learn the most from our errors?, 26

Analyzing patient safety incidents, 36

Conclusion, 43

References, 43

4 Equipment and Technical Errors in Veterinary Anesthesia, 45

Cases, 47

Near miss vignettes, 51

Conclusion, 57

References, 58

5 Medication Errors in Veterinary Anesthesia, 59

Cases, 60

Near miss vignettes, 66

Conclusions, 69

References, 69

6 Errors of Clinical Reasoning and Decision -making in Veterinary Anesthesia, 71

Cases, 72

Near miss vignettes, 85

Conclusion, 87

References, 87

7 Errors of Communication and Teamwork in Veterinary Anesthesia, 89

Cases, 89

Near miss vignette, 95

Conclusion, 96

References, 97

8 Error Prevention in Veterinary Anesthesia, 99

General strategies for error prevention, 100

Specific strategies for error prevention, 104

Conclusion, 119

References, 119

Appendix A. Suggested Readings, 121

Appendix B. Terminology, 123

Appendix C. ACVAA Monitoring Guidelines, 127

Appendix D. ACVAA Guidelines for Anesthesia in Horses, 131

Appendix E. A Brief History of Checklists, 133

Appendix F. FDA Anesthesia Apparatus Checkout, 135

Appendix G. Association of Veterinary Anaesthetists Anaesthetic Safety Checklist, 137

Appendix H. Critical Clinical Condition Checklists, 139

Index, 149

Author Information