Limitation of Supervision

Abstract

Weiler Division of Montefiore Medical Center, Bronx, New York. BobLagasse@yahoo.comIn Reply:—The suggestion to include “limitation of supervision” in the classification of human errors would not change the previously reported anesthesia-related mortality rate of approximately 1 per 13,000 anesthetics. 1Consider an anesthetic involving a perioperative death judged by peer review to be due to a limitation of supervision on the part of the attending anesthesiologist. That means, by definition, that the attending anesthesiologist was unable to prevent a resident anesthesiologist or nurse anesthetist from committing a human error because of multiple supervisory responsibilities being performed as expected. The human error committed by the resident anesthesiologist or nurse anesthetist would also be recorded as a result of our peer-review process. As noted in the Discussion, “Anesthesia-related mortality was defined as a perioperative death to which human error on the part of the anesthesia provider, as defined by our peer review process, had contributed (p 1613).” The term anesthesia provider includes attending anesthesiologists, resident anesthesiologists, and nurse anesthetists at our institution. Therefore, cases involving the system error limitation of supervision are counted among the anesthesia-related deaths because they also involve a human error by a supervised anesthesia provider. Interested parties may find more detailed descriptions of this peer-review model in previous issues of Anesthesiology. 2,3