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1. Clinical excellence is not achieved only by the use of sound medical knowledge. Human factors and the interaction of team members play a major role as well. Therefore, the study of human performance and related organizational matters is very important.
2. In dynamic domains like anesthesia, continuous decision-making, as described in the cognitive process model, is critical to achieve safe patient care.
3. Several error mechanisms have been demonstrated through human factors research. Understanding these psychological "traps" (for example, "fixation errors") can help the anesthetist to avoid or mitigate them.
4. A particular technique of human factors research called "task analysis" has been useful in understanding the work of anesthetists.
5. Observations of anesthetists during routine operations or in the handling of adverse events (using realistic patient simulators) has improved our knowledge of critical decision-making and team interactions.
6. The health care system in general and clinical institutions in particular must provide appropriate organizational characteristics to allow and foster safe patient care practices.
7. High reliability organization theory describes the key features of systems that conduct complex and hazardous work with very low failure rates. Health care should adopt many of these features.
8. Like all human beings, the performance of individual anesthetists can be adversely influenced by "performance-shaping factors." These include noise, illness, aging, and especially sleep deprivation (and fatigue).
9. Future progress on patient safety in anesthesia requires interdisciplinary research and training, the development and application of insightful incident reporting and analysis, and the involvement of all levels of the industry.