2017 Volume 37 Issue 1 Pages 1-5
We analyzed the serious accidents reported by an anesthesia practice between 2012 and 2014 using the original SHELL model. The model classifies accidents based on a human（liveware）, environmental, hardware and software. A total of 53 incidents and accidents reported from 2012 to 2014 were drug administration in nine cases, epidural technique in nine cases, anesthesia procedure in eight cases, blood transfusion in five cases, circulatory failure in four cases, complications related to endotracheal intubation in four cases, patient position during surgery in three cases, sterile technique in one case, and non-specific causes in 10 cases. Based on the SHELL model, the serious accidents derived from human factors which include misunderstandings, a lack of clarified instructions, communication failures, as well as insufficient knowledge, skills, and/or experience. Some of the serious accidents were associated with protocol（software）, equipment（hardware）, and environmental factors.
