Patient safety

Selected bibliography supporting the ten essential objectives for safe surgery

2. The team will use methods known to prevent harm from anesthetic administration, while protecting the patient from pain.

Arbous, M. S., A. E. Meursing, et al. (2005). "Impact of anesthesia management characteristics on severe morbidity and mortality." Anesthesiology 102: 257-68.

  • From a prospectively defined cohort of patients who underwent either general, regional or combined anaesthesia from 1 January 1995 to 1 January 1997 (n = 869 483), all consecutive patients (n = 811) who died within 24 h or remained unintentionally comatose 24 h after anaesthesia were classified to determine a relationship with anaesthesia. These deaths (n = 119; 15%) were further analysed to identify contributing aspects of the anaesthetic management, other factors and the appropriateness of care. The incidence of 24-h peri-operative death per 10 000 anaesthetics was 8.8 (95% CI 8.2-9.5), of peri-operative coma was 0.5 (0.3-0.6) and of anaesthesia-related death 1.4 (1.1-1.6). Of the 119 anaesthesia-related deaths, 62 (52%) were associated with cardiovascular management, 57 (48%) with other anaesthetic management, 12 (10%) with ventilatory management and 12 (10%) with patient monitoring. Inadequate preparation of the patient contributed to 30 (25%) of the anaesthesia-related deaths. During induction of anaesthesia, choice of anaesthetic technique (n = 18 (15%)) and performance of the anaesthesiologist (n = 8 (7%)) were most commonly associated with death. During maintenance, the most common factors were cardiovascular management (n = 43 (36%)), ventilatory management (n = 12 (10%)) and patient monitoring (n = 12 (10%)). In both the recovery and the postoperative phases, patient monitoring was the most common factor (n = 12 (10%) for both). For cardiovascular, ventilatory and other anaesthetic management, human failure contributed to 89 (75%) deaths and organisational factors to 12 (10%). For inadequate patient monitoring, human factors contributed to 71 (60%) deaths and organisational factors to 48 (40%). Other contributing factors were inadequate communication (30 deaths (25%) for all four aspects of the anaesthetic management) and lack of supervision (particularly for ventilatory management). Inadequate care was delivered in 19 (16%) of the anaesthesia-related deaths with respect to cardiovascular management, in 20 (17%) with respect to ventilatory management, in 18 (15%) with respect to patient monitoring and in 23 (19%) with respect to other anaesthetic management.

Cooper, J. B., R. S. Newbower, et al. (1978). "Preventable anesthesia mishaps: a study of human factors." Anesthesiology 49(6): 399-406.

  • A modified critical-incident analysis technique was used in a retrospective examination of the characteristics of human error and equipment failure in anesthetic practice. The objective was to uncover patterns of frequently occurring incidents that are in need of careful prospective investigation. 47 interviews were conducted with staff and resident anesthesiologists at one urban teaching institution, and descriptions of 359 preventable incidents were obtained. 23 categories of details from these descriptions were subjected to computer-aided analysis for trends and patterns. Most of the preventable incidents involved human error, with breathing-circuit disconnections, inadvertent changes in gas flow, and drug-syringe errors being frequent problems.

Eichhorn, J. H., J. B. Cooper, et al. (1986). "Standards for patient monitoring during anesthesia at Harvard Medical School." Jama 256(8): 1017-20.

  • As part of a major patient safety/risk management effort, the Department of Anaesthesia of Harvard Medical School, Boston, has devised specific, detailed, mandatory standards for minimal patient monitoring during anesthesia at its nine component teaching hospitals. Such standards have not previously existed, and resistance to the concept was anticipated but not seen. The standards are technically achievable in all settings and affordable in terms of effort and cost. Early detection of untoward trends or events during anesthesia will result in prevention or mitigation of patient injury; this, in turn, may also help counter the explosive increases in anesthesia-related malpractice actions, settlements, judgments, and insurance premiums. The committee process used is applicable to the promulgation of standards of practice for all medical specialties and any organized group of medical practitioners.

Gaba, D. M., K. J. Fish, et al. (1994). Crisis Management in Anesthesiology. New York, Churchill Livingston.

Hodges, S. C., C. Mijumbi, et al. (2007). "Anaesthesia services in developing countries: defining the problems." Anaesthesia 62(1): 4-11.

  • We describe the use of a questionnaire to define the difficulties in providing anaesthesia in Uganda. The results show that 23% of anaesthetists have the facilities to deliver safe anaesthesia to an adult, 13% to deliver safe anaesthesia to a child and 6% to deliver safe anaesthesia for a Caesarean section. The questionnaire identified shortages of personnel, drugs, equipment and training that have not been quantified or accurately described before. The method used provides an easy and effective way to gain essential data for any country or national anaesthesia society wishing to investigate anaesthesia services in its hospitals. Solutions require improvements in local management, finance and logistics, and action to ensure that the importance of anaesthesia within acute sector healthcare is fully recognised. Major investment in terms of personnel and equipment is required to modernise and improve the safety of anaesthesia for patients in Uganda.

International Task Force on Anaesthesia Safety (1993). "International standards for a safe practice of anaesthesia." European Journal of Anaesthesiology 10 (Suppl. 7): 12-15.

Runciman, W. B. (1993). "Risk assessment in the formulation of anaesthesia safety standards." European Journal of Anaesthesiology - Supplement 7: 26-32.

  • Risk assessment involves identifying hazards and then estimating their chance of occurrence and their severity. Risk management involves the cost-effective reduction of risk to levels perceived to be acceptable to society; risk levels set by experts may not be accepted, as perceived risk is strongly influenced by the nature of the adverse outcome and the context in which it was incurred. An understanding of the psychology of risk perception may lessen the negative impact of disasters and may better prepare the victims and their relatives. In formulating the international anaesthesia safety standards an attempt was made to base decisions on sound risk assessment and management principles. A review of the literature revealed that the hazards which posed most risks to patients were hypoxic gas mixtures, gas flow, circuit, endotracheal tube, airway and ventilation problems. These constituted one to two thirds of all incidents during anaesthesia, and account for most causes of brain damage that are dealt with by medical insurance companies. The size of the settlements provides evidence that these are viewed as very serious problems. Minimum standards were formulated with this information in mind; in recommending a sequence for equipment purchases great emphasis was placed on preventing the patient from breathing hypoxic gas mixtures, and on continuous monitoring of the adequacy of the airway, ventilation, the circulation and tissue oxygenation. [References: 26]

Runciman, W. B. (2005). "Iatrogenic harm and anaesthesia in Australia." Anaesthesia & Intensive Care 33(3): 297-300.

World Federation of Societies of Anaesthesiologists (WFSA). (Endorsed by the General Assembly of the WFSA at the 14th World Congress of Anaesthesiologists on 7 March 2008). "2008 International Standards for Safe Practice of Anaesthesia." Retrieved 26 May 2008, from