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Anesthesiology Risk Analysis Model

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Author(s): Azadeh Khalatbari | Kouroush Jenab

Journal: International Journal of Engineering
ISSN 1985-2312

Volume: 3;
Issue: 1;
Start page: 12;
Date: 2009;
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Keywords: Anesthesia | Medical Systems | Human Errors | Markov Model

ABSTRACT
This paper focuses on the human error identified as an important risk factor in theoccurrence of the anesthesia-related deaths. Performing clinical root cause analysis,the common anesthesia errors and their causes classified into four major problems (i.e.,breathing, drug, technical, and procedural problems) are investigated. Accordingly, aqualitative model is proposed that analyzes the influence of the potential causes of thehuman errors in these problems, which can lead to anesthetic deaths. Using riskmeasures, this model isolates these human errors, which are critical to anesthesiologyfor preventive and corrective actions. Also, a Markovian model is developed toquantitatively assess the influence of the human errors in the major problems andsubsequently in anesthetic deaths based on 453 reports over nine month.
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