The Original SHELL Model Revealed Human Factors as the Main Causes of Medical Malpractices Related to Anesthesia Practices between 2012 and 2014 in a Single Tertiary Center

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  • ICHIKAWA Junko
    Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
  • NISHIYAMA Keiko
    Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
  • KODAKA Mitsuharu
    Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
  • KOMORI Makiko
    Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East

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  • 過去3年間における麻酔関連のインシデント・アクシデントのSHELL分析に基づく解析

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<p>We analyzed the serious accidents reported by an anesthesia practice between 2012 and 2014 using the original SHELL model. The model classifies accidents based on a human（liveware）, environmental, hardware and software. A total of 53 incidents and accidents reported from 2012 to 2014 were drug administration in nine cases, epidural technique in nine cases, anesthesia procedure in eight cases, blood transfusion in five cases, circulatory failure in four cases, complications related to endotracheal intubation in four cases, patient position during surgery in three cases, sterile technique in one case, and non-specific causes in 10 cases. Based on the SHELL model, the serious accidents derived from human factors which include misunderstandings, a lack of clarified instructions, communication failures, as well as insufficient knowledge, skills, and/or experience. Some of the serious accidents were associated with protocol（software）, equipment（hardware）, and environmental factors.</p>

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