[Measures for reducing the risks of anesthesia].

To reduce the risks to human health and life has become an increasing demand by society. Physicians and engineers must develop and adopt measures to reduce such risks. The administration of anesthesia may be viewed as a closed-loop control system consisting of three major components: the anaesthesia system, the patient, and the system operator. An analysis of human element involved in the administration of anaesthesia indicates that the human brain is best qualified to make intelligent decisions; however, the reliance on human vigilance for the continuing monitoring of monotonous processes is questionable. Human error may be divided into slips, mistakes and omissions, each of them requiring different means of prevention. The events during a critical incident follow a certain sequence. Preventive measures can best be prepared by analyzing this sequence. The designer of medical equipment has four different approaches available to prevent injury to the patient: (1) to design the equipment which prevents a human error, (2) to design the equipment that injury is not possible when the human error occurs, (3) to warn of the possibility of a human error, or (4) to monitor for changes of important parameters which indicate the beginning of a critical situation. The most important safety measure is an integrated monitoring system with centralized, structured alarm announciation.