CONTENTS (click red text for selected chapter samples)
Foreword. p1
SECTION A: The Problem.
Chapter 1. My experiences with anesthesia drug errors. p4
Chapter 2. Overview: Risk factors for anesthesia drug errors. p20
Chapter 3. Selected illustrative drug error cases. p27
Chapter 4. The anesthesia death rate. p35
Chapter 5. DEFINITIONS: Rational Anesthesia Medication Administration Errors. p41
Chapter 6. CLASSIFICATIONS of Anesthesia Medication Administration Errors. p58
Chapter 7. INCIDENCE of Anesthesia Drug errors – The Webster Number. p74
Chapter 8. INCIDENCE of Regional Anesthesia drug errors. p110
Chapter 9. Unintended intra-arterial drug injections. p165
Chapter 10. Hospital ward nurse drug administration errors. p174
Chapter 11. Dentistry anesthesia drug errors. p180
Chapter 12. Veterinary anesthesia drug errors. p191
Chapter 13. Manufacturer drug errors. p193
Chapter 14. Sabotaged drug administration. p206
SECTION B. Errors in other Industries and Human Error.
Chapter 15. Highest risk drugs for injury if swapped for another drug. p225
Chapter 16. Human error and human reliability. p233
Chapter 17. Lessons learned from aviation errors. p249
Chapter 18. Is being human a crime? Criminalizing human error. p266
Chapter 19. Defensive medicine, and No-Faulty injury compensation. p288
Chapter 20. The Ethics of Drug Errors, Just Culture, and Culture of Safety. p310
Chapter 21. Managing and designing error reporting systems. p323
Chapter22. Protection of drug error reports, and Patient Safety Analysis. p335
Chapter 23. Investigating Anesthesia drug administration errors. p344
Chapter 24. Black Box studies to uncover anesthesia drug errors. p375
Chapter 25. Patient Safety Organizations and Patient Safety Officers. p380
Chapter 26. The story of RaDonda Vaught. p403
SECTION C. Root Causes and Risk Factors.
Chapter 27. The Cognitive Science behind Human Error. p411
Chapter 28. What is cognitive psychology? p423
Chapter 29. The Cognitive Science of DISTRACTIONS. p448
Chapter 30. The Cognitive Science of MULTITASKING. p486
Chapter 31. The Neurophysiology of subvocalizing thoughts and reading. p506
Chapter 32. Sleep Deficit and Mental Fatigue. p518
Chapter 33. Cognitive Aberrations and Emotions causing Drug Errors. p544
Chapter 34. ERGONOMICS in Anesthesia Drug Safety. p554
Chapter 35. Helping the Second Victim; the Erring Anesthesiologist. p558
SECTION D: The Solution.
Chapter 36. FIXING THE SYSTEM to Prevent Human Error. p567
Chapter 37. Managing discovered Wrong Route Drug Injection Errors. p602
Chapter 38. Look-Alike vials and ampules: Identification Techniques. p616
Chapter 39. Color-Coding syringe drug labels. p641
Chapter 40. READABILITY of syringe drug labels. p662
Chapter 41. High-Level TECHNOLOGY to IDENTIFY drugs and syringes. p692
Chapter 42. Low-Level TECHNOLOGIES to reduce anesthesia drug errors. 715
Chapter 43. The DUEL role of PHARMACISTS in anesthesia drug errors. 730
Chapter 44. Supplementary technology for Drug INVENTORY and INJECT PORTS. p736
Chapter 45. Advanced Anesthesia Support Personnel: Anesthesia Techs. p757
Chapter 46. SMART DRUGS to improve cognition. p764
Chapter 47. Managing the Bullying Surgeon. p775
Chapter 48. EDUCATION on anesthesia Drug Errors. 780
Chapter 49. Invisible, undiscovered, and concealed anesthesia drug errors. p782
Chapter 50. The MOMENT when an anesthesia drug administration error occurs. p.784
Chapter 51. Supplementary case reports on anesthesia drug errors. p787
Chapter 52. What the ANESTHESIOLOGIST can do to reduce drug errors. p789
Chapter 53. What POLITICIANS + MANAGERS can do to reduce drug errors. p792
Chapter 54. What TECHNOLOGY INDUSTRY can do to reduce drug errors. p793
Chapter 55. Book SUMMARY Best Points. p795
Chapter 56. Anesthesia Drug Errors Book CONCLUSION. p.802
INDEX. p809
A
2A
B
CONTENTS (click red text for selected
chapter samples)
Foreword. p1
SECTION A: The Problem.
Chapter 1. My experiences with anesthesia drug errors.
p4
Chapter 2. Overview: Risk factors for anesthesia drug
errors. p20
Chapter 3. Selected illustrative drug error cases. p27
Chapter 4. The anesthesia death rate. p35
Chapter 5. DEFINITIONS: Rational Anesthesia
Medication Administration Errors. p41
Chapter 6. CLASSIFICATIONS of Anesthesia Medication
Administration Errors. p58
Chapter 7. INCIDENCE of Anesthesia Drug errors – The
Webster Number. p74
Chapter 8. INCIDENCE of Regional Anesthesia drug errors. p110
Chapter 9. Unintended intra-arterial drug injections. p165
Chapter 10. Hospital ward nurse drug administration errors. p174
Chapter 11. Dentistry anesthesia drug errors. p180
Chapter 12. Veterinary anesthesia drug errors. p191
Chapter 13. Manufacturer drug errors. p193
Chapter 14. Sabotaged drug administration. p206
SECTION B. Errors in other Industries and Human
Error.
Chapter 15. Highest risk drugs for injury if swapped for another drug. p225
Chapter 16. Human error and human reliability. p233
Chapter 17. Lessons learned from aviation errors. p249
Chapter 18. Is being human a crime? Criminalizing human error. p266
Chapter 19. Defensive medicine, and No-Faulty injury compensation. p288
Chapter 20. The Ethics of Drug Errors, Just Culture, and Culture of Safety. p310
Chapter 21. Managing and designing error reporting systems. p323
Chapter22. Protection of drug error reports, and Patient Safety Analysis. p335
Chapter 23. Investigating Anesthesia drug administration errors. p344
Chapter 24. Black Box studies to uncover anesthesia drug errors. p375
Chapter 25. Patient Safety Organizations and Patient Safety Officers. p380
Chapter 26. The story of RaDonda Vaught. p403
SECTION C. Root Causes and Risk Factors.
Chapter 27. The Cognitive Science behind Human Error. p411
Chapter 28. What is cognitive psychology? p423
Chapter 29. The Cognitive Science of DISTRACTIONS. p448
Chapter 30. The Cognitive Science of MULTITASKING. p486
Chapter 31. The Neurophysiology of subvocalizing thoughts and reading. p506
Chapter 32. Sleep Deficit and Mental Fatigue. p518
Chapter 33. Cognitive Aberrations and Emotions causing Drug Errors. p544
Chapter 34. ERGONOMICS in Anesthesia Drug Safety. p554
Chapter 35. Helping the Second Victim; the Erring Anesthesiologist. p558
SECTION D: The Solution.
Chapter 36. FIXING THE SYSTEM to Prevent Human Error. p567
Chapter 37. Managing discovered Wrong Route Drug Injection Errors. p602
Chapter 38. Look-Alike vials and ampules: Identification Techniques. p616
Chapter 39. Color-Coding syringe drug labels. p641
Chapter 40. READABILITY of syringe drug labels. p662
Chapter 41. High-Level TECHNOLOGY to IDENTIFY drugs and syringes. p692
Chapter 42. Low-Level TECHNOLOGIES to reduce anesthesia drug errors. 715
Chapter 43. The DUEL role of PHARMACISTS in anesthesia drug errors. 730
Chapter 44. Supplementary technology for Drug INVENTORY and INJECT PORTS.
p736
Chapter 45. Advanced Anesthesia Support Personnel: Anesthesia Techs. p757
Chapter 46. SMART DRUGS to improve cognition. p764
Chapter 47. Managing the Bullying Surgeon. p775
Chapter 48. EDUCATION on anesthesia Drug Errors. 780
Chapter 49. Invisible, undiscovered, and concealed anesthesia drug errors. p782
Chapter 50. The MOMENT when an anesthesia drug administration error occurs.
p.784
Chapter 51. Supplementary case reports on anesthesia drug errors. p787
Chapter 52. What the ANESTHESIOLOGIST can do to reduce drug errors. p789
Chapter 53. What POLITICIANS + MANAGERS can do to reduce drug errors. p792
Chapter 54. What TECHNOLOGY INDUSTRY can do to reduce drug errors. p793
Chapter 55. Book SUMMARY Best Points. p795
Chapter 56. Anesthesia Drug Errors Book CONCLUSION. p.802
INDEX. p809
2C
CONTENTS (click red text for selected chapter
samples)
Foreword. p1
SECTION A: The Problem.
Chapter 1. My experiences with anesthesia drug errors. p4
Chapter 2. Overview: Risk factors for anesthesia drug errors. p20
Chapter 3. Selected illustrative drug error cases. p27
Chapter 4. The anesthesia death rate. p35
Chapter 5. DEFINITIONS: Rational Anesthesia Medication
Administration Errors. p41
Chapter 6. CLASSIFICATIONS of Anesthesia Medication Administration
Errors. p58
Chapter 7. INCIDENCE of Anesthesia Drug errors – The Webster
Number. p74
Chapter 8. INCIDENCE of Regional Anesthesia drug errors. p110
Chapter 9. Unintended intra-arterial drug injections. p165
Chapter 10. Hospital ward nurse drug administration errors. p174
Chapter 11. Dentistry anesthesia drug errors. p180
Chapter 12. Veterinary anesthesia drug errors. p191
Chapter 13. Manufacturer drug errors. p193
Chapter 14. Sabotaged drug administration. p206
SECTION B. Errors in other Industries and Human Error.
Chapter 15. Highest risk drugs for injury if swapped for another drug. p225
Chapter 16. Human error and human reliability. p233
Chapter 17. Lessons learned from aviation errors. p249
Chapter 18. Is being human a crime? Criminalizing human error. p266
Chapter 19. Defensive medicine, and No-Faulty injury compensation. p288
Chapter 20. The Ethics of Drug Errors, Just Culture, and Culture of Safety. p310
Chapter 21. Managing and designing error reporting systems. p323
Chapter22. Protection of drug error reports, and Patient Safety Analysis. p335
Chapter 23. Investigating Anesthesia drug administration errors. p344
Chapter 24. Black Box studies to uncover anesthesia drug errors. p375
Chapter 25. Patient Safety Organizations and Patient Safety Officers. p380
Chapter 26. The story of RaDonda Vaught. p403
SECTION C. Root Causes and Risk Factors.
Chapter 27. The Cognitive Science behind Human Error. p411
Chapter 28. What is cognitive psychology? p423
Chapter 29. The Cognitive Science of DISTRACTIONS. p448
Chapter 30. The Cognitive Science of MULTITASKING. p486
Chapter 31. The Neurophysiology of subvocalizing thoughts and reading. p506
Chapter 32. Sleep Deficit and Mental Fatigue. p518
Chapter 33. Cognitive Aberrations and Emotions causing Drug Errors. p544
Chapter 34. ERGONOMICS in Anesthesia Drug Safety. p554
Chapter 35. Helping the Second Victim; the Erring Anesthesiologist. p558
SECTION D: The Solution.
Chapter 36. FIXING THE SYSTEM to Prevent Human Error. p567
Chapter 37. Managing discovered Wrong Route Drug Injection Errors. p602
Chapter 38. Look-Alike vials and ampules: Identification Techniques. p616
Chapter 39. Color-Coding syringe drug labels. p641
Chapter 40. READABILITY of syringe drug labels. p662
Chapter 41. High-Level TECHNOLOGY to IDENTIFY drugs and syringes. p692
Chapter 42. Low-Level TECHNOLOGIES to reduce anesthesia drug errors. 715
Chapter 43. The DUEL role of PHARMACISTS in anesthesia drug errors. 730
Chapter 44. Supplementary technology for Drug INVENTORY and INJECT PORTS. p736
Chapter 45. Advanced Anesthesia Support Personnel: Anesthesia Techs. p757
Chapter 46. SMART DRUGS to improve cognition. p764
Chapter 47. Managing the Bullying Surgeon. p775
Chapter 48. EDUCATION on anesthesia Drug Errors. 780
Chapter 49. Invisible, undiscovered, and concealed anesthesia drug errors. p782
Chapter 50. The MOMENT when an anesthesia drug administration error occurs. p.784
Chapter 51. Supplementary case reports on anesthesia drug errors. p787
Chapter 52. What the ANESTHESIOLOGIST can do to reduce drug errors. p789
Chapter 53. What POLITICIANS + MANAGERS can do to reduce drug errors. p792
Chapter 54. What TECHNOLOGY INDUSTRY can do to reduce drug errors. p793
Chapter 55. Book SUMMARY Best Points. p795
Chapter 56. Anesthesia Drug Errors Book CONCLUSION. p.802
INDEX. p809
2B
