This document discusses strategies to improve patient safety during anesthesia. It identifies that anesthesia can induce physiological changes that increase morbidity and mortality risks, so factors threatening safety in the operating room must be addressed. These factors include equipment issues, patient health problems, and human errors by anesthetists and surgeons. The document recommends developing preoperative plans, maintaining situational awareness during procedures, emphasizing teamwork and communication, avoiding production pressures, and fostering a learning culture where errors are reported and used to implement safety improvements.

2. Anesthesia has the potential to induce
physiological changes that may lead to
morbidity and mortality. As a result, it
is commonly regarded as a high-risk
activity.
So we should find out factors
threatening patient safety in the
operation room and search for
strategies to deal with them.

3. •Causes: Design flaw, User
error or Malfunction
•Strategies: pre-use
checkout
Equipment
•Causes: Underlying
diseases or Allergic
reaction
•Strategies: Preoperative
evaluations
Patient
•Causes: Human factors
affecting performance
•Strategies: Improve
human reliability
Anesthetist
and
Surgeon
 Accidents in healthcare
system have always multi-
factorial causes.
 System failure is the main
reason for accidents.
 Human error is a strong
contributor
o Deviation from
policies & guidelines
o Lapse in vigilance

5. Anesthesia
Plan
Preoperative
patient
assessment
Check
machines &
monitors
PREOPERATIVE PLAN
Prepare
efficient
workspace
Label all
medications
Check
backup
equipment

6. SITUATIONAL
AWARENESS
Rapid
reassessment
in case of any
abnormal
vital sign
Use systematic
approach for
scanning

7. • Cross-check observations
• Compensatory responses: time-buying measure then treat
• In critical crises: call for help then use emergency protocols
• Teamwork communication & delegation
• Stress reduction & work environment optimization
• Production pressure avoidance: patient safety must be the priority
• Learning culture: any error is an opportunity to improve

8. Our goal is improvement the
quality of care & minimizing
the risk of injuries from
anesthesia.
1) Documentation:
Any adverse event should
be reported truthfully to be
analyzed and apply
strategies to prevent its
reoccurrence.

9. 2)Standards and guidelines:
Anesthetists should be aware
of the hospital’s policies &
procedures concerning of
patient safety. e.g., adverse
event reporting, hand-off
checklists, resuscitation
protocols& preoperative
testing

10. 3) Safety training:
The best way to learn critical-
event management skills is using
simulator. After training on
simulator repeatedly, when crisis
happens, you can manage it
efficiently.

11. Qualified anesthetist shall be
present in the room throughout
the course of anesthesia care.
Continually evaluate the patient's
respiration ,circulation and
temperature.

12. All of information should be clearly
presented:
o Perioperative Management
The patient's diagnosis, surgery, allergies, past medical and
surgical history, relevant medications, and any pertinent normal or
abnormal laboratory values
o 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

14. Provide
continuous
patient care
Notify the
anesthesia
operating room
administrator&
Contact
consultant as
needed
Document
events in the
patient record
(including the
serial number of
the anesthesia
machine)
Not discard
supplies or
tamper with
equipment.
Submit a follow-
up report to TQM
department
Document
continuing
care in the
patient's
record