Raising awareness on awareness – Case Report
DOI:
https://doi.org/10.25751/rspa.9871Keywords:
Awareness, Intraoperative complications, Root cause analysisAbstract
Awareness is a rare though important complication of general anaesthesia that still occurs in the present, with an estimated incidence of 1-2:1000 general anaesthetics. We present the case of a 63-year-old female patient with breast cancer presenting for unilateral mastectomy, sentinel lymph node excision and placement of short-term tissue expander under general anaesthesia, who experienced intraoperative awareness.
We then set out to perform a root cause analysis in search of contributing factors in this particular case, acknowledging the importance of automatic data collection systems in this type of investigation.
A systematic search for the underlying cause should always be performed, as its importance extends not only the patient directly involved but also to subsequent cases, given that potentially repeatable errors or unsuspected equipment malfunction may be unveiled.
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