John W. Ludders, DVM, DipACVAA, is Professor Emeritus at Cornell University in Ithaca, New York, USA.Matthew McMillan, BVM&S, DipECVAA, MRCVS, is Principal Clinical Anaesthetist and Critical Care Co-ordinator at Queen’s Veterinary School Hospital at the University of Cambridge in Cambridge, United Kingdom.

• Preface, ixAcknowledgments, xiIntroduction, xiii1 Errors: Terminology and Background, 1Error: terminology, 1Conclusion, 5References, 52 Errors: Organizations, Individuals, and Unsafe Acts, 7Error causation: technical factors, 7Error causation: organizational and supervision factors, 7Error causation: environmental factors, 12Error causation: personnel factors, 12Error causation: human factors, 12Error causation: other factors, 22Conclusion, 22References, 223 Reporting and Analyzing Patient Safety Incidents, 25The limitation in only counting errors, 25How can we learn the most from our errors?, 26Analyzing patient safety incidents, 36Conclusion, 43References, 434 Equipment and Technical Errors in Veterinary Anesthesia, 45Cases, 47Near miss vignettes, 51Conclusion, 57References, 585 Medication Errors in Veterinary Anesthesia, 59Cases, 60Near miss vignettes, 66Conclusions, 69References, 696 Errors of Clinical Reasoning and Decision-making in Veterinary Anesthesia, 71Cases, 72Near miss vignettes, 85Conclusion, 87References, 877 Errors of Communication and Teamwork in Veterinary Anesthesia, 89Cases, 89Near miss vignette, 95Conclusion, 96References, 978 Error Prevention in Veterinary Anesthesia, 99General strategies for error prevention, 100Specific strategies for error prevention, 104Conclusion, 119References, 119Appendix A. Suggested Readings, 121Appendix B. Terminology, 123Appendix C. ACVAA Monitoring Guidelines, 127Appendix D. ACVAA Guidelines for Anesthesia in Horses, 131Appendix E. A Brief History of Checklists, 133Appendix F. FDA Anesthesia Apparatus Checkout, 135Appendix G. Association of Veterinary Anaesthetists Anaesthetic Safety Checklist, 137Appendix H. Critical Clinical Condition Checklists, 139Index, 149

"This book serves as definitive reading for all faculty, residents, interns and technicians in veterinary anesthesiology...Each chapter provides excellent clinical vignettes of mistakes and inaccuracies....For anyone looking to improve their practice of veterinary medicine or formulating a system for morbidity-mortality rounds, this book is essential reading. Excellent." (Doody Enterprises 24/03/2017)"Errors in Veterinary Anesthesia is an informative and necessary read for anyone interested in starting and managing an anesthesia service in a progressive veterinary practice or a large veterinary institution. It delves deeply into the subject and describes how errors in anesthesia are made and what can be done to prevent or correct them"....... "I was particularly engaged by the book’s introduction because it describes a management culture that, in my opinion, has been overlooked consciously or unconsciously by veterinary medicine"...... "One of the strengths of this book is the 4 chapters devoted to actual clinical scenarios in which errors were made or near misses occurred and how they were handled"..... "I think this book will also appeal and be very useful to the managers of forward-thinking general practices. Overall, I recommend this book to anyone looking to improve their anesthetic and personnel management skills" (Reviewed by Dianna Ovbey, DVM, MS, DACVAASoutheast Veterinary Anesthesia Services, Charleston, SC 15th June 2017 AVMA)

John W. Ludders, DVM, DipACVAA, is Professor Emeritus at Cornell University in Ithaca, New York, USA.Matthew McMillan, BVM&S, DipECVAA, MRCVS, is Principal Clinical Anaesthetist and Critical Care Co-ordinator at Queen’s Veterinary School Hospital at the University of Cambridge in Cambridge, United Kingdom.

• Preface, ixAcknowledgments, xiIntroduction, xiii1 Errors: Terminology and Background, 1Error: terminology, 1Conclusion, 5References, 52 Errors: Organizations, Individuals, and Unsafe Acts, 7Error causation: technical factors, 7Error causation: organizational and supervision factors, 7Error causation: environmental factors, 12Error causation: personnel factors, 12Error causation: human factors, 12Error causation: other factors, 22Conclusion, 22References, 223 Reporting and Analyzing Patient Safety Incidents, 25The limitation in only counting errors, 25How can we learn the most from our errors?, 26Analyzing patient safety incidents, 36Conclusion, 43References, 434 Equipment and Technical Errors in Veterinary Anesthesia, 45Cases, 47Near miss vignettes, 51Conclusion, 57References, 585 Medication Errors in Veterinary Anesthesia, 59Cases, 60Near miss vignettes, 66Conclusions, 69References, 696 Errors of Clinical Reasoning and Decision-making in Veterinary Anesthesia, 71Cases, 72Near miss vignettes, 85Conclusion, 87References, 877 Errors of Communication and Teamwork in Veterinary Anesthesia, 89Cases, 89Near miss vignette, 95Conclusion, 96References, 978 Error Prevention in Veterinary Anesthesia, 99General strategies for error prevention, 100Specific strategies for error prevention, 104Conclusion, 119References, 119Appendix A. Suggested Readings, 121Appendix B. Terminology, 123Appendix C. ACVAA Monitoring Guidelines, 127Appendix D. ACVAA Guidelines for Anesthesia in Horses, 131Appendix E. A Brief History of Checklists, 133Appendix F. FDA Anesthesia Apparatus Checkout, 135Appendix G. Association of Veterinary Anaesthetists Anaesthetic Safety Checklist, 137Appendix H. Critical Clinical Condition Checklists, 139Index, 149

"This book serves as definitive reading for all faculty, residents, interns and technicians in veterinary anesthesiology...Each chapter provides excellent clinical vignettes of mistakes and inaccuracies....For anyone looking to improve their practice of veterinary medicine or formulating a system for morbidity-mortality rounds, this book is essential reading. Excellent." (Doody Enterprises 24/03/2017)"Errors in Veterinary Anesthesia is an informative and necessary read for anyone interested in starting and managing an anesthesia service in a progressive veterinary practice or a large veterinary institution. It delves deeply into the subject and describes how errors in anesthesia are made and what can be done to prevent or correct them"....... "I was particularly engaged by the book’s introduction because it describes a management culture that, in my opinion, has been overlooked consciously or unconsciously by veterinary medicine"...... "One of the strengths of this book is the 4 chapters devoted to actual clinical scenarios in which errors were made or near misses occurred and how they were handled"..... "I think this book will also appeal and be very useful to the managers of forward-thinking general practices. Overall, I recommend this book to anyone looking to improve their anesthetic and personnel management skills" (Reviewed by Dianna Ovbey, DVM, MS, DACVAASoutheast Veterinary Anesthesia Services, Charleston, SC 15th June 2017 AVMA)

John W. Ludders, DVM, DipACVAA, is Professor Emeritus at Cornell University in Ithaca, New York, USA.Matthew McMillan, BVM&S, DipECVAA, MRCVS, is Principal Clinical Anaesthetist and Critical Care Co-ordinator at Queen’s Veterinary School Hospital at the University of Cambridge in Cambridge, United Kingdom.

• Preface, ixAcknowledgments, xiIntroduction, xiii1 Errors: Terminology and Background, 1Error: terminology, 1Conclusion, 5References, 52 Errors: Organizations, Individuals, and Unsafe Acts, 7Error causation: technical factors, 7Error causation: organizational and supervision factors, 7Error causation: environmental factors, 12Error causation: personnel factors, 12Error causation: human factors, 12Error causation: other factors, 22Conclusion, 22References, 223 Reporting and Analyzing Patient Safety Incidents, 25The limitation in only counting errors, 25How can we learn the most from our errors?, 26Analyzing patient safety incidents, 36Conclusion, 43References, 434 Equipment and Technical Errors in Veterinary Anesthesia, 45Cases, 47Near miss vignettes, 51Conclusion, 57References, 585 Medication Errors in Veterinary Anesthesia, 59Cases, 60Near miss vignettes, 66Conclusions, 69References, 696 Errors of Clinical Reasoning and Decision-making in Veterinary Anesthesia, 71Cases, 72Near miss vignettes, 85Conclusion, 87References, 877 Errors of Communication and Teamwork in Veterinary Anesthesia, 89Cases, 89Near miss vignette, 95Conclusion, 96References, 978 Error Prevention in Veterinary Anesthesia, 99General strategies for error prevention, 100Specific strategies for error prevention, 104Conclusion, 119References, 119Appendix A. Suggested Readings, 121Appendix B. Terminology, 123Appendix C. ACVAA Monitoring Guidelines, 127Appendix D. ACVAA Guidelines for Anesthesia in Horses, 131Appendix E. A Brief History of Checklists, 133Appendix F. FDA Anesthesia Apparatus Checkout, 135Appendix G. Association of Veterinary Anaesthetists Anaesthetic Safety Checklist, 137Appendix H. Critical Clinical Condition Checklists, 139Index, 149

"This book serves as definitive reading for all faculty, residents, interns and technicians in veterinary anesthesiology...Each chapter provides excellent clinical vignettes of mistakes and inaccuracies....For anyone looking to improve their practice of veterinary medicine or formulating a system for morbidity-mortality rounds, this book is essential reading. Excellent." (Doody Enterprises 24/03/2017)"Errors in Veterinary Anesthesia is an informative and necessary read for anyone interested in starting and managing an anesthesia service in a progressive veterinary practice or a large veterinary institution. It delves deeply into the subject and describes how errors in anesthesia are made and what can be done to prevent or correct them"....... "I was particularly engaged by the book’s introduction because it describes a management culture that, in my opinion, has been overlooked consciously or unconsciously by veterinary medicine"...... "One of the strengths of this book is the 4 chapters devoted to actual clinical scenarios in which errors were made or near misses occurred and how they were handled"..... "I think this book will also appeal and be very useful to the managers of forward-thinking general practices. Overall, I recommend this book to anyone looking to improve their anesthetic and personnel management skills" (Reviewed by Dianna Ovbey, DVM, MS, DACVAASoutheast Veterinary Anesthesia Services, Charleston, SC 15th June 2017 AVMA)