Evidence Based Practice and Quality Assurance
Background and Goal of Study: Anaesthesiologists have an accumulated body of experience that can be used in risk management. How can one gather and systematise that lived experience in a way that can be useful in risk management.
Materials and Methods: Gathering and ranking of risk factors by means of a relation matrix filled in by senior anaesthesiologists (n > 43).
Results and Discussions: The information that emerged from the accumulated live experience of the senior anaesthesiologists points to a set of 3 groups of risk factors:
poor leadership; poor communication; lacking of clear tested procedures (1°group)
production pressure; long hours (2°group)
poor facilities; poor or missing equipment; shortage of trained professionals (3°group)
Conclusion(s): Relation matrix can be a useful method for acquiring and systematizing lived experience data into information relevant to risk management in anaesthesiology, providing a retrospective blame-free tool since it can be used anonymously.
1 To Err Is Human: Building a Safer Health System (2000), Institute of Medicine.
2 Cooper JB, Newbower RS and all Preventable anesthesia mishaps: a study of human factors Quality and Safety in Health Care 2002;11:277-283.