Case Studies of Near Misses in Clinical Anesthesia

All anesthesiologists eventually face the fear of a “near miss,” when a patient’s life has been put at risk.  Learning from the experience is crucial to professionalism and the ongoing development of expertise. Drawing on forty-plus years of practice in major metropolitan hospitals in the United States, Norway, and South Africa, John Brock-Utne, MD presents 80 carefully selected cases that provide the basis for lessons and tips to prevent potential disaster.  The cases emphasize problem-centered learning and span a broad range of topics—from an outbreak of operating room infection (could it be the anesthesia equipment?),  complications of fiberoptic intubations,  and problems with epidural drug pumps, to performing an urgent tracheostomy for the first time, working with an aggressive surgeon, and what to do when a patient falls off  the operating table during surgery.  80 true-story clinical “near misses” never before published, ideal for problem-centered learning, recommendations, references, and discussions accompany most cases, rich basis for teaching discussions both in or out of the operating room, settings include sophisticated as well as rudimentary anesthetic environments, complements the author’s other case book, Clinical Anesthesia: Near Misses and Lessons Learned (Springer, 2008).

From the reviews:“Provides a wealth of tips to prevent perioperative disaster and is ideal for problem-based discussions … . case scenarios that are informative and useful for practitioners in all anesthetic subspecialties and for those practicing in different environments … . I would highly recommend this book to anyone practicing anesthesiology … . It is always prudent to heed the advice of those more experienced than ourselves; with this book, Dr. Brock-Utne has solidified some of those lessons on paper to be shared for the future.” (Eric S. Fouliard, Anesthesiology, Issue 4, 2013)“This book includes interesting cases from the author’s (and his colleagues’) 40+ year anesthesia career. … The purpose is to present near-miss cases and the etiology of the problems. … This is a great book for anyone interested, even peripherally, in anesthesia and critical care medicine. It would be a great read for medical students or student registered nurse anesthetists as well as residents and practitioners. It is such an easy read that it can be picked up and put down quickly.”­­­ (Martin Dauber, Doody’s Book Reviews, December, 2011)

John Brock-Utne is an Emeritus Professor of Anesthesia and a previous Associate Director of the Anesthesia Residency Program at Stanford University School of Medicine.  He has written over 200 peer-reviewed articles and about 400 abstracts and letters, and several books, including Near Misses in Pediatric Anesthesia and Clinical Anesthesia: Near Misses and Lessons Learned.