Patient Safety in Anesthesia Care

Julie Brightwell, JD, RN, Director, Healthcare System Patient Safety, Department of Patient Safety and Risk Management

Safe anesthesia care begins with the preoperative assessment and continues through the postoperative period. To help you keep your patients safe and avoid liability risks, we highlight common risk areas and offer strategies for practice improvement.

Preanesthetic Evaluation

Patient harm and claims occur when anesthesia providers fail to review the information available in the medical record. Allow time for a thorough preanesthetic assessment with review of all preoperative laboratory tests, diagnostic studies, and consultations. If the patient was sent for preoperative evaluation, address any recommendations prior to starting the procedure. If you disagree with any of the recommendations, discuss them with the evaluating physician and document the discussion. Work with the surgeons, proceduralists, and healthcare organization to coordinate sufficient time for the patient assessment and testing. Avoid the pressure to proceed with only a cursory examination and record review.

A thorough preanesthetic evaluation includes completing a detailed physical examination of the patient’s airway and soliciting a history of any airway difficulties. Use a classification system, such as Mallampati, and document the assessed airway features to demonstrate that you performed a comprehensive airway exam. If a difficult airway is anticipated, formulate a plan for induction and emergence that includes the necessary equipment and additional assistance. For more information, see the Practice Guidelines for Management of the Difficult Airway from the American Society of Anesthesiologists (ASA).

Many patients who have obstructive sleep apnea (OSA) have not yet been diagnosed. The use of a screening tool, such as the STOP-BANG Sleep Apnea Questionnaire, can be useful in identifying patients who may be at risk.

Informed Consent

The informed consent process includes engaging the patient in a discussion of the types of anesthesia or sedation that are available, the risks and benefits of each type, and any alternatives. The discussion should include the risks of dental damage, special positioning, and any additional procedures, such as central or arterial lines.

Some patients testify that they do not recall their anesthesia provider discussing any risks. To memorialize this important discussion, use an anesthesia-specific informed consent document that is separate from the surgical consent. Provide the patient with an opportunity to ask questions.

For patients undergoing regional anesthesia, explain the potential need to convert to general anesthesia, and obtain patient consent in advance. The known complications of nerve blocks, including peripheral nerve injury, should also be disclosed and documented.

Dental Damage

Dental injuries remain the most frequently encountered adverse event in anesthesia. Performing and documenting a dental exam and including dental injury as an identified risk in your informed consent discussion may be effective in mitigating the exposure. This process can be especially important for patients with poor dentition, cosmetic dentistry procedures, or those identified as having a potentially difficult airway. Ask patients specific questions related to their teeth, such as the presence of caps, crowns, bridges, or loose teeth, and whether dental work is temporary or permanent.

Universal Protocol

Wrong patient, wrong procedure, wrong side or site, and wrong position are still frequent sources of patient harm and provider liability. To prevent these types of “never events,” actively participate in the time out prior to the start of any surgical or invasive procedure. If multiple procedures are scheduled on the same patient, a time out should take place prior to each procedure.

An article published by the American Society of Regional Anesthesia and Pain Medicine identified several studies showing wrong-site nerve blocks as being even more prevalent than wrong-site surgeries, and the numbers could increase as nerve blocks replace prescription opioids for pain management. Follow the universal protocol of preprocedure verification, anesthesia site marking, and a time out prior to the performance of an anesthetic block.

Intraoperative Care

Adverse anesthesia events can occur despite the use of sophisticated monitors if alarms have been silenced during a case or were silenced at the end of the prior case and not reactivated. The ASA Standards for Basic Anesthetic Monitoring require that alarms be audible to the members of the anesthesia care team.

Reassess the patient when equipment appears to be malfunctioning. The most frequent cognitive errors made by anesthesia providers are relying on monitors, ignoring monitors, and assuming that equipment is defective rather than examining the patient.

Teamwork and high-reliability principles for patient safety require communicating concerns about the patient’s physiological condition to the entire team. Many anesthesia providers are reluctant to speak up about the patient’s condition until they detect severe or prearrest symptoms.

Steps taken to maintain normothermia during surgery should be documented. Use care in warming efforts, especially in patients who may be frail or have thin skin (such as the very young or the very old), as burns can occur easily and are a source of claims.

Operating room fires occur about 600 times each year.Follow fire prevention guidelines to (1) control heat and ignition sources, including electrosurgical units, heated equipment, and lasers; (2) manage fuels, such as skin prepping solutions, ointments, and dry dressings; and (3) reduce oxidizers by minimizing oxygen concentrations and tented surgical draping. In the event an operating room fire occurs, appropriate equipment and supplies must be immediately available. The organization’s emergency plan should include practice drills with surgical, operating room, and anesthesia personnel so that all team members are familiar with their fire management roles.

Postanesthesia Care

Critical respiratory events continue to occur postanesthesia due to immediate or prolonged respiratory depression from a variety of causes. These events can stem from opioid use, inadequate reversal of neuromuscular blockade, or risk factors associated with OSA. Failure to recognize surgical complications that compromise the airway, such as hematomas or edema from head and neck surgeries, also play a role in postoperative respiratory events.

In cases with prolonged neuromuscular blockade, each patient should be objectively evaluated to ensure that adequate reversal has occurred. This is demonstrated when the train-of-four ratio is 0.9 or greater.2

For patients with known or suspected OSA, follow ASA Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea, which include the use of pulse oximetry postoperatively and consideration of regional analgesic techniques without opioids during the postoperative period. Include OSA precautions in handoff communications to the PACU staff and other inpatient units, and as part of discharge instructions to the patient and family for outpatient procedures.

Since many adverse respiratory events occur after the patient is discharged from the PACU and transferred to a regular nursing floor, implement continued respiratory monitoring using multiple parameters that include vital sign and oxygen saturation monitoring.3 Staff training should include policies for patients with known or suspected OSA and early recognition of postanesthetic and surgical complications.

For additional information from The Doctors Company on safe anesthesia care, read our Anesthesiology Closed Claim Study.


  1. Jones TS, Black IH, Robinson TN, Jones, EL. Operating room fires. Anesthesiology. 2019 Mar;130(3):492-501.
  2. Brull SJ, Kopman AF. Current status of neuromuscular reversal and monitoring: challenges and opportunities. Anesthesiology. 2017 Jan;126(1):173-190.
  3. Khanna A. Respiratory depression in the postoperative period. Updated Oct 10, 2019.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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