Application of Teleonic Principles in the Search for Systemic Causes of Accidents in Anesthesia

Abstract

Safety of patients in anesthesia has always been one of the major concerns of the anesthetist. It is clear from studies of safety in general that many accidents and critical incidents occur as the result of latent systemic failures to which a great number of factors contribute (Reason, 1990). An ideal way to approach this problem would be within a systemic framework, such as teleonics, developed by Jaros and his co-workers (Cloete, 1999; Jaros and Cloete, 1987, 1993). In this framework the events and procedures in anesthesia are considered to be part of a very complex network of process systems (teleons). It is postulated that teleonic uncertainty (telentropy) in this complex network is a factor that might lead to accidents. In a previous paper presented to the World Congress at Toronto in 2000, the principles of teleonics were described in a mathematico symbolic way (Horvath et al., 2000). This paper contains selected examples of application of these principles to the identification of possible systemic causes of accidents in anesthesia.