Errors and omissions in anesthesia: a pilot study using a pilot's checklist

Anesth Analg. 2005 Jul;101(1):246-50, table of contents. doi: 10.1213/01.ANE.0000156567.24800.0B.


There are recent concerns that anesthesiologists are becoming less skilled in providing general anesthesia for Cesarean delivery. We considered whether a verbal checklist would help in the preparation for this event. We created a list of items to be checked when preparing to administer general anesthesia for a Cesarean delivery using expert opinion. This list was loaded onto an electronic checklist system with voice prompts and tested on 20 anesthesiologists using a high-fidelity anesthesia simulator. Participants omitted to check a median of 13 (range, 7-23) of 40 items. Common omissions included not checking that the difficult intubation trolley was available and not optimizing the patient's head position. Most (95%) participants felt that the checklist was useful and 80% would like to use it for practicing simulated scenarios; 60% preferred a written checklist and 40% preferred the verbal checklist. Important checks may be forgotten when preparing to give a general anesthetic for Cesarean delivery, and the use of a checklist could improve patient safety.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Anesthesia / standards*
  • Anesthesiology / instrumentation*
  • Anesthetics
  • Aviation / instrumentation*
  • Cesarean Section
  • Female
  • Humans
  • Medical Errors / prevention & control*
  • Monitoring, Intraoperative / instrumentation
  • Pilot Projects
  • Pregnancy


  • Anesthetics