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

被引：18

作者：

Spiess, Bruce D. ^{[1
,2
,3
]}

Rotruck, John ^{[4
]}

McCarthy, Harry ^{[1
,2
,3
]}

Suarez-Wincosci, Olga ^{[1
,2
,3
]}

Kasirajan, Vigneshwar ^{[1
,2
,3
]}

Wahr, Joyce ^{[5
]}

Shappell, Scott ^{[6
]}

机构：

[1] Virginia Commonwealth Univ, Med Ctr, Dept Anesthesiol, Richmond, VA 23298 USA

[2] Virginia Commonwealth Univ, Med Ctr, Dept Cardiac Surg, Richmond, VA 23298 USA

[3] Virginia Commonwealth Univ, Med Ctr, Dept Perfus, Richmond, VA 23298 USA

[4] Natl Naval Med Ctr, Dept Anesthesiol, Bethesda, MD USA

[5] Univ Minnesota, Dept Anesthesiol, Minneapolis, MN 55455 USA

[6] Embrey Riddle Aeronaut Univ, Dept Human Factors & Syst, Daytona Beach, FL USA

来源：

JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA | 2015年 / 29卷 / 01期

关键词：

human factors; patient safety; cardiopulmonary bypass; oxygen failure; hypoxemia; cerebral oximetry; near miss; CLASSIFICATION-SYSTEM; SURGICAL MORTALITY; ADVERSE EVENTS; HUMAN ERROR; ACCIDENTS; SURGERY; HFACS; FOCUS;

D O I：

10.1053/j.jvca.2014.08.011

中图分类号：

R614 [麻醉学];

学科分类号：

100217 ;

摘要：

[No abstract available]

引用

页码：204 / 209

页数：6

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