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Safety in the nonoperating room anesthesia suite is not an accident

lessons from the National Transportation Safety Board

Walls, Jason D.a; Bramble, William J. Jrb; Weiss, Mark S.a

Current Opinion in Anesthesiology: August 2019 - Volume 32 - Issue 4 - p 504–510
doi: 10.1097/ACO.0000000000000751

Purpose of review To review the findings of National Transportation Safety Board-related aviation near misses and catastrophes and apply these principles to the nonoperating room anesthesia (NORA) suite.

Recent findings NORA is a specialty that has seen tremendous growth. In 2019, NORA contributes to a larger proportion of anesthesia practice than ever before. With this growth, the NORA anesthesiologist and team are challenged to provide safe, high-quality care for more patients, often with complex comorbidities, and are forced to utilize deeper levels of sedation and anesthesia than ever before. These added pressures create new avenues for human error and adverse outcomes.

Summary Safety in modern anesthesia practice often draws comparison to the aviation industry. From distinct preoperational checklists, defined courses of action, safety monitoring and the process of guiding individuals through a journey, there are many similarities between the practice of anesthesia and flying an airplane. Consistent human performance is paramount to creating safe outcomes. Although human errors are inevitable in any complex process, the goal for both the pilot and physician is to ensure the safety of their passengers and patients, respectively. As the aviation industry has had proven success at managing human error with a dramatic improvement in safety, a deeper look at several key examples will allow for comparisons of how to implement these strategies to improve NORA safety.

aDepartment of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

bOffice of Aviation Safety, National Transportation Safety Board, Washington, DC, USA

Correspondence to Jason D. Walls, MD, Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA. Tel: +1 215 662 3773; e-mail:

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