Features  |   February 2018
The Journey to High-Reliability Anesthesia Outside of the Operating Room
Author Affiliations
  • Mohamed Mahmoud, M.D.
    Committee on Ambulatory Surgical Care
  • Keira P. Mason, M.D.
    Committee on Ambulatory Surgical Care
Article Information
Patient Safety / Pediatric Anesthesia / Quality Improvement / Features
Features   |   February 2018
The Journey to High-Reliability Anesthesia Outside of the Operating Room
ASA Monitor 02 2018, Vol.82, 18-21.
ASA Monitor 02 2018, Vol.82, 18-21.
Serious medical errors and harm can occur in any health care organization and no one should believe that “this event could and should never happen at my institution.” As humans, we all make errors. Vigilance, working harder or simply “doing our best” is not sufficient to ensure and sustain patient safety. When a safety event occurs it usually includes a series of human errors that are unfortunately often supported by system or culture failures which enable, or encourage the mistake. The important consequence from any mistake should be an assessment of why it happened, since the majority of medical errors are multifactorial and attributable to system flaws, processes, and conditions that foster human error or fail to prevent them.1 
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