Human Factors Analysis of a Near-Miss Event: Oxygen Supply Failure During Cardiopulmonary Bypass

Bruce D. Spiess; John Rotruck; Harry McCarthy; Olga Suarez-Wincosci; Vigneshwar Kasirajan; Joyce Wahr; Scott Shappell

doi:10.1053/j.jvca.2014.08.011

Human Factors Analysis of a Near-Miss Event: Oxygen Supply Failure During Cardiopulmonary Bypass

Bruce D. Spiess, John Rotruck, Harry McCarthy, Olga Suarez-Wincosci, Vigneshwar Kasirajan, Joyce Wahr, Scott Shappell

Human Factors & Behavioral Neurobiology

Research output: Contribution to journal › Article › peer-review

Abstract

Reducing preventable medical injuries is a compelling urgent goal of the healthcare industry and government alike. Near-miss events should be analyzed as early warnings to teams so that they reduce the possibility than an individual error will go unchecked.

Original language	American English
Journal	Journal of Cardiothoracic and Vascular Anesthesia
Volume	29
DOIs	https://doi.org/10.1053/j.jvca.2014.08.011
State	Published - Feb 2015

Keywords

human factors
patient safety
cardiopulmonary bypass
oxygen failure
hypoxemia
cerebral oximetry
near miss

Disciplines

Cardiology
Surgery

Access to Document

10.1053/j.jvca.2014.08.011License: Unspecified

Cite this

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title = "Human Factors Analysis of a Near-Miss Event: Oxygen Supply Failure During Cardiopulmonary Bypass",

abstract = " Reducing preventable medical injuries is a compelling urgent goal of the healthcare industry and government alike. Near-miss events should be analyzed as early warnings to teams so that they reduce the possibility than an individual error will go unchecked.",

keywords = "human factors, patient safety, cardiopulmonary bypass, oxygen failure, hypoxemia, cerebral oximetry, near miss",

author = "Spiess, {Bruce D.} and John Rotruck and Harry McCarthy and Olga Suarez-Wincosci and Vigneshwar Kasirajan and Joyce Wahr and Scott Shappell",

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AU - Kasirajan, Vigneshwar

AU - Wahr, Joyce

AU - Shappell, Scott

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KW - cardiopulmonary bypass

KW - oxygen failure

KW - hypoxemia

KW - cerebral oximetry

KW - near miss

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DO - 10.1053/j.jvca.2014.08.011

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JO - Journal of Cardiothoracic and Vascular Anesthesia

JF - Journal of Cardiothoracic and Vascular Anesthesia

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