• Anesthetists are responsible for patient safety
• Anesthesiology is a high-risk specialty as
compared with other specialties in medicine
The risk of anesthesia
• Anesthesia may contribute to death in about 1
per 10,000 anesthetics.
• Many other patients suffer serious and costly
nonfatal injuries such as permanent
neurologic damage (paraplegia and
• Now we can see anesthesia event can cause
• So we should find out factors threatening
patient safety in the operation room and
search for strategies to deal with them
There are many factors threatening
patient safety in the operation rooms
– Underlying diseases: hyperthyroidism-thyroid
storm, diabetes-ketoacidosis or hyperosmolar
– Allergic reaction to some drug
– Preoperative evaluations
Anesthetist and Surgeon
• Human factors affecting performance such as
:fatigue noise, boredom, long hours, hunger,
• System failures are the main reason for
– Check anesthetic machine
– Oxygen supply
– A backup O2 tank
– Never shut down audible alarms (very important)
Emergency ventilation equipment
• Human error is a strong contributor
– Deviations from accepted anesthesia practices
– A lapse in vigilance and no attention to detail
• Vigilance and attention to detail are essential
for a safety conducted anesthetic.
• Vigilance lets anesthetists find abnormal signs
as early as possible
• Vigilance allows the anesthetist to to remain
aware of surrounding events and signals while
performing other tasks.
II. General safety strategies
A. Prepare a preoperative plan
• Preoperative visit to the patient
to let us know the patient’s
condition in detail.
• Make an anesthesia plan to let us
know clearly how to perform the
anesthesia and how to deal with
• Check anesthesia machine,
monitors and other devices.
• Prepare the workspace to make
us work mare conveniently and
efficiently. Arrange equipment
and appropriate monitors in a
way that facilitates this. So we
can clearly observe the patient
and easily manipulate all devices
• Check backup
• Know the location of
emergency supplies and
• Label all medications
B. Develop situational awareness
• Use systematic approach to scanning the
machine monitors, patient, surgical field, and
• If one vital sign is anomalous, quickly assess
the measurement and observing what is
happening on the surgical field.
C. Verify observations
Assess co varying variables
Review it with a second person.
D. Implement compensatory responses
If something wrong happens urgently, first
implementing time-buying measures. E.g.,
increase the fraction of inspired oxygen when
oxygen saturation falls; administer intravenous
fluids or vasopressors when hypotension
Then search out any correctable primary
cause and treat it appropriately.
E. Prepare for crisis
If there is any critical events happened
(cardiac arrest, malignant hyperthermia or
difficult intubation), call for help early (WHY),
then use accepted protocols for emergencies
and resuscitation (e.g., advanced cardiac life
support, malignant hyperthermia protocols).
F. Enhance teamwork; communicate
To enhance teamwork and communication,
address surgeons and nurses early in the case
by knowing names. Make requests and
delegate tasks clearly and specifically by name
(e.g., “Jack, do task X and tell me when task X
G. Compensate for stressors
Anesthetist is a stressful job. If you feel very
tires, ask for a relief.
Reduce various stressors: noise, fatigue,
interpersonal tension, etc. Optimize the work
H. Recognize and address production
• Patient safety must remain the highest priority
• In big hospitals, anesthetists have a greant deal of
workload. There are many operations everyday.
Anytime we can’t sacrifice patient safety in order
to emphasize production. If there is on adequate
preoperative evaluation, preparation, or
monitoring, it is unsafe to anesthetize the
patient. You must address concerns explicitly to
surgeons and cancel the operation.
I. Learn from close calls
Every mistake is an opportunity to learn and
Analysis and feedback of adverse events to
identify and assess system problems.
III. Crucial errors to know and avoid
A. Airway errors
As we know, patients receiving general
anesthesia have no spontaneous respiration
due to use of muscular relaxants, their
respiration is controlled by machine via endo-
trecheal tube. So we must ensure oxygen
supply and avoid accidental extubation
during sugeries ( esp. a prone surgery) and
transport. Once it happens, the result is
severe. It can cause severe hypoxia and
directly threaten the patient life.
How to avoid
• Check the system and guarantee it to function
• Verify an endotracheal tube by auscultating
for breath sounds bilaterally and by detecting
• Fix the tube solidly
• Closely observe vital signs
Verify an endotracheal tube
B. Medication errors
• Administration of undiluted potassium by
rapid intravenous infusion can cause
ventricular fibrillation and cardiac arrest.
• Neostigmine given without an antimuscarinic
drug can cause asystole, severe bradycardia
and antrioventricular block and can be fatal.
• Succinylcholine can cause severe
hyperkalemia and dysrhythmias, may trigger
• Medications to which a patient is allergic can
• Administering the wrong blood can cause an
incompatibility reaction that can be fatal.
How to avoid
• Be familiar with the medication you use, know
clearly its indications and contraindications.
• Administrate the medication strictly according
• Know the patient’s history of allergy
• Cross-check blood type.
c. Procedure errors
• Inadvertent intravascular injection of local
anesthetics during a nerve block can cause
neurologic and cardiac toxicity, which can be fatal
(especially with bupivacaine).
• Avoidable epidural hematomas may develop
when spinal or epidural anesthetics are
performed in patients who have coagulopathies.
• Air embolisms may occur during the placement
or removal of central venous catheters and may
cause significant hemodynamic instability.
(decumbens position can avoid it).
How to avoid
• Adequate preoperative evaluation of patients
• Manipulation according to standards and
IV. Quality assurance
• The aim is improving the quality of care and
minimizing the risk of injury from anesthesia.
• Any adverse events should be reported
truthfully, discussed, analyzed to identify
causes and assess system problems. So we can
learn from them and develop patterns to
B. Standards and guidelines
• Anesthetists should be aware of their
institution’s safety policies and procedures.
These should include those for monitoring,
response to an adverse event, handoff
checklist, resuscitation protocols,
perioperative testing, and any special
procedures or practices for the use of drugs,
equipment, and supplies.
C. Safety training
• Anesthesia providers should obtain training in
safety to learn and maintain basic skills.
Simulation techniques should be used. In
reality, for one doctor, the opportunity to
confront a critical event is rare, the best way
to learn critical-event management skill is
using simulator. After training on simulator
repeatedly, when crisis happens, you can
manage it efficiently.
V. Standards and protocols
Standards for basic anesthetic
1. Qualified anesthesia personnel shall be
present in the room throughout the course of
all general anesthetics, regional anesthetics,
and monitored anesthesia care.
2. Continually evaluated the patient’s
respiration, circulation and temperature.
2.1 Respiratory monitor
– An oxygen analyzer
– Pulse oximeter
– Clinical signs
– Continual end-tidal carbon dioxide analysis must be
used with tracheal intubation.
– Some form of monitoring with an audible alarm must
be used during mechanical ventilation.
2.2 Cardiac vascular monitor
• Continuous EKG
• Blood pressure and heart rate at least every 5
• One or more of the following
– Palpation of a pulse
– Auscultation of heart sound
– Pulse oximetry
• CVP and arterial blood pressure
2.3 Temperature monitor
• When clinically significant changes in body
temperature are intended, anticipated, or
• Periodic breaks should be given to the primary
individuals providing anesthesia.
• The following information should be clearly
a. Prior clinical details
• The patient’s diagnosis, surgery, allergies, past
medical and surgical history, relevant
medications, and any pertinent normal or
abnormal laboratory values or studies.
b. Intraoperative management
• Status of surgery, airway assessment and
management techniques, anesthetic plan and
current status, current vital signs with an
explanation for any apparent abnormalities or
trends, intravenous access and monitoring,
blood loss and volume status assessment,
anticipated need for additional medications
(e.g., narcotics, muscle relaxation or reversal,
Guidelines for action after an adverse
The anesthesiologist involved in an adverse
event should do the following:
a. Provide for continuing care of the patient.
b. Notify the anesthesia operating room
administrator as soon as possible. If a
resident or certifield registration
• The objectives are to limit patient injury from
a specific adverse event associated with
anesthesia and to ensure that the causes of
the event are identified so that a recurrence
can be prevented.