Bell Graham
Department of Anaesthetics, Royal Hospital for Sick Children, Glasgow, UK.
Paediatr Anaesth. 2011 Jul;21(7):758-64. doi: 10.1111/j.1460-9592.2011.03590.x. Epub 2011 Apr 26.
This review will attempt to put the various systems that allow clinicians to assess errors, omissions, or avoidable incidents into context and where possible, look for areas that deserve more or less attention and resource specifically for those of us who practice pediatric anesthesia. Different approaches will be contrasted with respect to their outputs in terms of positive impact on the practice of anesthesia. These approaches include audits by governmental organizations, national representative bodies, specialist societies, commissioned boards of inquiry, medicolegal sources, and police force investigations. Implementation strategies are considered alongside the reports as the reports cannot be considered end points themselves. Specific areas where pediatric anesthetics has failed to address recurring risk through any currently available tools will be highlighted.