LOOKING BACK ON THE ANESTHESIA CRITICAL INCIDENT STUDIES AND THEIR ROLE IN CATALYSING PATIENT SAFETY

In 1978 Cooper and colleagues published their landmark paper¹ on the application of the critical incident technique,² adapted from uses in aviation and other fields, to examine the causes—and later prevention strategies—for adverse anesthesia outcomes. Following on 20 years of rudimentary anesthesia mortality studies, this was a brilliant approach that gave anesthesia clinicians new insights on which we could act. As the report told us: “. . . factors associated with anesthetists and/or that may have predisposed anesthetists to err have, with a few exceptions, not been previously analyzed. Furthermore, no study has focused on the process of error—its causes, the circumstances that surround it, or its association with specific procedures, devices, etc—regardless of final outcome.” Data from the study at one hospital and from an extension to four hospitals 6 years later³ provided two widely cited tables listing “the most frequent incidents” and “summary of associated factors cited”. This innovative examination of critical events provided the first useful mirror for clinicians to reflect on their practice. In that mirror we were able to see how our imperfections could lead to errors and patient injury.

In my view this study was one of a few pivotal events responsible for the dramatic success in promoting anesthesia patient safety, starting with Beecher and Todd's …