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Anesthesiology:
doi: 10.1097/ALN.0b013e31816d8124
Reviews of Educational Material

Avoiding Common Anesthesia Errors.

Kazanjian, Paul E. M.D.
Section Editor(s): Warner, Mark A. M.D., Editor

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Avoiding Common Anesthesia Errors. Edited by Catherine Marcucci, M.D., Norman A. Cohen, M.D., David G. Metro, M.D., and Jeffrey R. Kirsch, M.D. Philadelphia, Lippincott Williams & Wilkins, 2007. Pages: 704. Price: $54.95.
The Institute of Medicine and other organizations claim that human error results in an alarming number of iatrogenic injuries and deaths each year. The American Society of Anesthesiologists Closed Claims Project provides insight into the character but not the incidence of adverse outcomes in anesthesia. Just how common are errors in medicine and anesthesia, specifically? Minor errors—of little or no consequence to patient outcome—may occur quite frequently but are seldom reported. Some of these minor errors represent “near misses” or “close calls,” narrowly avoiding death or injury. Avoiding errors, whether minor or major, requires education, training, good judgment, vigilance, and experience. We learn how to minimize or reduce errors not only from our personal education and experience but from the experience and insight of our colleagues.
Catherine Marcucci et al. have compiled an extensive collection of short treatises on a great number of issues and errors in our practice. Eighteen editors and nearly 200 contributors cover more than 200 topics in this 704-page-long softcover book. Chapters are arranged in sections, and each chapter is approximately four to six pages long.
Sections cover the obligatory basic subject areas such as airway and ventilation, lines and access, and medications. Interestingly, there are also sections on legal issues, professional practice, coding, and billing. The implication is that errors in our practice extend beyond clinical management of our patients. While the book title suggests a focus on “common errors,” several chapters cover topics that are only peripherally related to errors per se.
A valuable feature of the book is the practical usefulness of the table of contents itself. Simply perusing the titles of the chapters will provide the reader with numerous practical tips and bits of advice. For example, chapter 57 is titled, “Do Not Forget that Linezolid Is a Monoamine Oxidase Inhibitor (MAOI) as well as an Antibiotic.” The chapter titles also entice the reader to delve into the topics. Chapter 97's title, “Do Not Use Your Cell Phone in the Operating Room,” and chapter 77's title, “Be Aware that Schizophrenic Patients Have Greater Perioperative Risks than Age-matched Controls,” beg the questions “Why?” and “Really?” Explanations, answers, and advice are easily obtained after reading short chapters that conclude with “take home points.” For those readers who are compelled to learn even more, there is a list of suggested readings at the end of each chapter.
The editors do not offer a systematic approach to reducing errors in anesthesia practice. This is not a textbook on medical error. In fact, the editors claim that the book originated as an effort to write down the clinical pearls that are verbally passed from senior to junior staff. As chapter 177 begins, “People may understand statistics, but they believe stories.” Much of the subject material seems to have originated from bits of experience, tales of terror, words of wisdom, and anecdotal observations. That is not to say that the material is invalid, opinionated, or unfounded; most chapters seem to be balanced and accurate. Certainly, this is not the heady science of academia or the whimsical whispers heard in ivory towers. Instead, the reviews and advice are concise, pragmatic, and clinical.
Most of us prioritize our approach to high-risk situations by evaluating and managing the ABCs, and so it is with this book. The first sections and chapters cover topics pertaining to the airway, ventilation, circulation, and resuscitation. Instead of starting with the ABCs, users of this book may benefit by beginning their reading near the end of the book. The chapters in the section titled “Human Factors” provide the groundwork for understanding the nature and genesis of errors in medicine. In fact, the material in this section could be used as framework for tying together all the myriad material in the other chapters by assisting the reader in analyzing, comprehending, and understanding the specific instances of error. For example, it might have been instructive for the authors or editors to analyze each example of error in light of the human factors that contribute to error in general. The authors could have offered whether any particular error was primarily due to a failure in communication, leadership, conflict management, vigilance, or a combination of these factors.
Even without a cohesive theme or approach, the book remains immensely valuable as a one-stop compendium of common error-prone clinical situations. The brief chapters stand on their own and can be read and assimilated quickly and painlessly. Analyzing the situations for a common denominator, understanding why the errors are common, and providing a systematic approach to reducing the incidence of untoward events in anesthesia will remain the task of another edition of this text or a separate text.
Paul E. Kazanjian, M.D.
University of Michigan Medical School, Ann Arbor, Michigan. kazanjia@med.umich.edu

© 2008 American Society of Anesthesiologists, Inc.

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