Improving safety and preventing human error

in anesthesiology practice through the application of simple technology

Andrew Bowdle
September 26, 2013

There is a growing realization that simple, preventable mistakes are responsible for many of the bad outcomes of medical care, and that greater attention to preventing errors could save many lives.  The progressive and dramatic improvements in the safety of commercial aviation are often used as an analogy to how this could be accomplished in medicine.  Anesthesiology has seen dramatic improvements in safety over the years, due primarily to technological advances in monitoring and the development of anesthetic drugs with fewer adverse effects.  However, much work remains to be done to improve safety in anesthesiology, as in other medical specialties.  Our recent work has focused on preventing mechanical complications of central venous catheter insertion, and the prevention of anesthetic drug administration errors (such as administration of the wrong drug).  We have explored the use of relatively simple and inexpensive technology to prevent common human errors.  We helped to develop and test an inexpensive, compact, sterile, single-use, pressure transducer to be used during insertion of central venous catheters that can greatly reduce the chance of accidentally inserting the catheter into an artery instead of a vein.  We have also developed, and performed a pilot study of an anesthetic drug safety system that utilizes bar codes and bar code readers to help prevent certain types of common drug administration errors.