Human error and its impact on anesthesiology

Health care in the United States is tragically complicated by medical error. This article focuses on understanding how we learn, how we err, and how the features of human cognition interact to produce errors in medical care. In terms of lives affected adversely and dollars lost to the economy, the magnitude of this problem is staggering. Federal and state governments are now involved in moving forward with private groups, third party-payors, and health care providers to bring the successes of other industries, such as commercial nuclear power and aviation, to the bedside. Anesthesiology has taken a first position in this effort with organizations like the Anesthesia Patient Safety Foundation (http://www.apsf.org) and tools such as the Crisis Management Manual from the Australian Patient Safety Foundation (http://www.apsf.net.au).