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A 46-year-old woman was scheduled for bronchoscopy and mediastinoscopy. Following uneventful induction of general anesthesia and tracheal intubation with an 8.0 mm endotracheal tube, bronchoscopy was performed. The upper thorax and neck were then prepped for mediastinoscopy using a standard iodine/alcohol surgical preparation solution (Iodine Povacrylex [0.7% available Iodine] and Isopropyl Alcohol, 74% w/w). The endotracheal tube was moved and secured to the right side of the patient's mouth, and the breathing circuit was secured to the side of the patient's head. Surgical incision and dissection were assisted with a standard electrosurgical unit. Approximately 10 minutes into the procedure, the anesthesiologist detected a breathing circuit leak. She checked all external connections and determined that the endotracheal tube pilot balloon was defective. To maintain effective ventilation, the endotracheal tube position was adjusted, additional air was added to the pilot balloon, and the circuit fresh gas flow was increased from 1 to 6 L/min. When the procedure was finished and the drapes removed, the anesthesiologist noted that the surgical drape on the right side of the patient's neck, near the endotracheal tube, was charred, and there was a 6 cm2 2nd and 3rd degree burn on the patient's right shoulder. In retrospect, an unusual smell was noted during the case by the operating room scrub nurse, but he attributed this to the leaking anesthetic gas and did not mention this to the rest of the surgical team.


Anesthesia practice is becoming progressively safer,1 and anesthesiology is recognized as the leading medical specialty in addressing patient safety.2 Nonetheless, patients are still harmed by their anesthesia care, mostly due to preventable human error.3 Thoracic anesthesia presents special risks to patients, owing to patient comorbidities and the complexity of both the surgical and anesthesia care required. Airway and ventilation management are shared anesthesiology and surgery concerns, requiring tight coordination of care through good communication. Issues such as monitoring and positioning, airway management and ventilation—important considerations in any case requiring general anesthesia—are complicated by the nature of the thoracic surgical intervention. Patients undergoing thoracic surgery often have preexisting pulmonary disease, cardiac disease, and other major medical problems. Indeed, thoracic surgical procedures are performed on sicker patients than in the past.4 These and other factors make the management of thoracic cases particularly challenging and can contribute to the likelihood of medical errors.


One of the most widely accepted paradigms for describing system failures is the Swiss cheese model put forth by James Reason.5 When adapted to the healthcare domain, this model stipulates that medical errors resulting in patient injury are seldom caused by a single mistake and rarely are they only the result of an individual provider's negligence. When an adverse event occurs, it is often a consequence of the alignment of "holes" in the different defensive layers (depicted as Swiss cheese slices) developed by healthcare organizations to prevent errors (Figure 2–1). These holes, or system weaknesses, arise for two ...

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