The article of Lienhart et al.  1must be applauded. Because of the authors’ careful and high-quality methodology, this work—begun in 1996 and covering an entire nation—was able to estimate anesthesia-related mortality in France. This work confirms the critical role of cardiac disease, aging, emergency care and hemorrhage in mortality related to anesthesia.

Perhaps more importantly, the authors illuminate the importance of human error. In at least 98% of cases, one episode of substandard practice was identified, and in more than half of the cases, four deviations from accepted practice were recorded. The authors acknowledge that their analysis probably underestimated the true incidence of such system error.

Production pressure was a factor in 20% of the events, but despite their belief that errors may occur more frequently during urgent and stressful care, the authors do not mention the role, if any, of a night shift or call, the night of or the 48 h before the accident. Several recent articles have linked fatigue in anesthesia with medical errors,2,3but because anesthesia deaths are rare events (according to the survey, occurring in less than 1 of 100,000 cases) and despite a rigorous methodology, analysis were unable to demonstrate a link between night shifts and anesthetic or intensive care mortality.4 

Because of the authors’ sample size and their careful analysis, the study could have provided a unique opportunity to analyze the role of sleep deprivation5in the genesis of anesthesia accidents. It would have been of interest to know whether this could have played a role in mortality related to anesthesia.

*Val-de-Grâce Military Hospital, Paris, France.

Lienhart A, Auroy Y, Pequignot F, Benhamou D, Warszawski J, Bovet M, Jougla E: Survey of anesthesia-related mortality in France. Anesthesiology 2006; 105:1087–97
Howard SK, Rosekind MR, Katz JD, Berry AJ: Fatigue in anesthesia: Implications and strategies for patient and provider safety. Anesthesiology 2002; 97:1281–94
Gaba DM, Howard SK: Patient safety: Fatigue among clinicians and the safety of patients. N Engl J Med 2002; 347:1249–55
Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA: Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351:1838–48
Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA: Neurobehavioral performance of residents after heavy night call versus  after alcohol ingestion. JAMA 2005; 294:1025–33