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Anecdotal and empirical evidence has drawn attention to the occurrence of procedural "violations" by healthcare professionals. These are actions that are not intended to cause harm, but that nevertheless breach established protocols and guidelines of practice. Violations can, if unchecked, potentially erode the margin of safety, thus increasing the likelihood of adverse events. They are therefore of concern to psychologists and human factors specialists working in patient safety.

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On rare occasions, halothane anaesthesia is associated with liver damage. Two forms of toxicity are now recognised - a mild form manifest by increased serum liver enzymes, and a rarer, fulminant form which may be fatal. The historical background, clinical features, morphology and epidemiology of halothane hepatitis are presented, and animal models of halothane hepatotoxicity are described; current perspectives on its aetiology are reviewed. The application of serum enzymes to the recognition of acute liver injury is reviewed, and the limitations of those in current use are described. The measurement of glutathione S-transferase (GST) in plasma by specific radioimmunoassay offers potential for the early detection of drug-induced, hepatocellular damage. The structure, classification, distribution and techniques for measurement of GST are presented, and experience with their use in various liver disorders is explored. The influence of general anaesthesia on several liver enzymes is examined, and the advantage of GST over conventional liver enzymes are discussed. The effects of halothane, enflurane and isoflurane anaesthesia on plasma GST concentration after operation are reported. GST concentration increased 3-6 hours after anaesthesia with halothane and enflurane, and more marked increases were observed at 24 hours in some of the patients who received these agents: GST did not increase at any time in patients who received isoflurane. The incidence of abnormal GST concentrations after anaesthesia with halothane, enflurane and isoflurane directly correlated with the incidence of reported clinical hepatic dysfunction for these drugs.

Acute haemorrhage cases are extremely difficult to analyse using randomised experimental studies and are well suited to computer modelling. The two main areas of current research are whether intravenous fluids should be administered to patients at the scene of an accident or not and what type of fluid should be given. A computer model was designed which analyses the fluid volume compartments within the human body. The relationship between the blood volume and blood pressure was examined, as was the transcipillary refill effect and the mechanics of the bleeding site. The model was then validated by comparing simulated predictions with previously published animal experiments for different sets of bleeding parameters. The agreement between published and predicted values of blood pressure and haematocrit was good (1.1% and 1.4 respectively). The model was then used to analyse the behaviour of intravenous fluids in trauma resuscitation. It was shown that crystalloid solutions do not follow the established pattern of leakage out of the intravascular system but that the half varies according to the degree of under resuscitation of the patient. The model was also used to determine the efficiency of three different accident site treatment protocols: no treatment, crystalloid infusion and colloid infusion. It was found that for shorter transport time (10-30 minutes) crystalloid infusion had to be at a high rate to be more efficient than no treatment. At high transport times (30-50 minutes) colloid infusion was more efficient that crystalloid and no treatment for medium infusion rates only.

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While conventional training and assessment of anaesthetists has placed great emphasis on the necessary clinical knowledge and practical skills to ensure competent practice, the non-technical aspects of performance such as team co-ordination and decision making that are essential for the safe and effective practice of anaesthesia have not been formally addressed. The aim of this thesis was to identify the non-technical skills used by anaesthetists in the operating theatre environment and to develop a behavioural marker system for observing and assessing these skills. Adapting research techniques used in aviation, four stages of research were conducted: 1) Anaesthetists' non-technical skills were identified through interviews using cognitive task analysis techniques with 29 consultant anaesthetists. 2) A team of anaesthetists and psychologists developed a prototype behavioural marker system. 3) This prototype was evaluated in an experimental study to investigate aspects of its validity, reliability and usability. 4) Finally, user trials were conducted in theatre to investigate practical use of the tool in a real environment; initial user guidance was developed. The result of the research was an empirically based behavioural marker system, called the Anaesthetists' Non-Technical Skills (ANTS) System, which with training can be used for observation, assessment and discussion of anaesthetists' non-technical skills. While the ANTS System has been recognised by the anaesthetic community as filing an important gap, from a research perspective, it is still in a relatively early stage of its development, and needs testing further in a broader range of environments.

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