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June 23, 1989

Near Misses in Anesthesia: Lessons Learned

JAMA. 1989;261(24):3620. doi:10.1001/jama.1989.03420240134041

This 98-page paperback contains a litany of anesthetic nightmares. The authors have collected 45 critical incidents from "actual experiences in nine different hospitals scattered over several states" and have presented them in brief, comprehensive, narrative formats, each of which challenges the reader to diagnose the problem before turning the page and learning the answer. Each narrative is followed by a brief description of the causative factors under the heading "Resolution." Each incident concludes with a discussion, and pertinent references are appended.

Episodes, from first—"The Case of the Tilted Timebomb"—to last—"The Case of the Sluggish Stream"—are alliteratively titled. As an example of the style and format used by the authors, the issue to be resolved in "Tilted Timebomb" is the postoperative hypertension/tachycardia that occurs in an elderly patient who, following vascular surgery, is treated for hypotension with head-down positioning while undergoing pressure-cycled mechanical ventilation. The lesson to be learned is that