Table of Contents  
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 1-4

Risk management and anesthesia

Lecturers, Department of Anesthesia, Intensive Care & Pain Management, Faculty of Medicine, Ain-Shams University, Cairo, Egypt

Date of Submission03-Jul-2013
Date of Acceptance18-Aug-2013
Date of Web Publication31-May-2014

Correspondence Address:
Marwa A Khairy
Department of Anesthesia, Intensive Care & Pain Management, Faculty of Medicine, Ain-Shams University, Cairo 11566
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1687-7934.128386

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Risk management in Anesthesia is a crucial part of patient safety. Because anesthesia care is usually considered as facilitative rather than therapeutic, the outcome of anesthesia care has traditionally been measured in terms of the absence of 'complications'. Consequently, anesthetists have been at the forefront of clinical risk management. It can be described in five stages as follows: risk awareness, risk identification, risk assessment, risk management, and re-evaluation. By identifying the strong points and the weakest points in concurrent health systems; policies and procedures can be implanted in order to ensure effective risk control. If applied correctly and not limited to compelling statistics, risk management can be a powerful, highly beneficial aid to our practice.

Keywords: Risk management, safety, system failures, polices

How to cite this article:
Khairy MA, Salem YA, Saleh M. Risk management and anesthesia. Ain-Shams J Anaesthesiol 2014;7:1-4

How to cite this URL:
Khairy MA, Salem YA, Saleh M. Risk management and anesthesia. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2023 Sep 29];7:1-4. Available from:

  Introduction Top

Anesthesia is a critical field in Health System as the anesthetized patient can be considered intrinsically at risk [1]. The problem with risk in anesthesia is the psychology of the perception of risk. Because anesthesia care is facilitative rather than therapeutic, the outcome of anesthesia care has traditionally been measured in terms of the absence of 'complications' [2].

The current incidence of minor events or complications is estimated at 18-22% during anesthesia, 0.45-1.4% for severe complications, and 1 : 100 000 for mortality. Evidence suggests that despite such low complication rates, further improvements can still be made if we know that a considerable proportion of anesthesia-related adverse events are preventable as risk factors can be detected and eliminated [3].

  Risk management Top

Adverse patient outcomes are the focus of risk management in anesthesia. The term 'risk' is best defined as the chance or probability of a poor outcome. This may be either fatal (death) or nonfatal (dysfunction), with the latter classified as disease, discomfort, and dissatisfaction [4].

Risk management is the anticipation and limitation of risk so as to decrease both the chance of suffering loss and the size of the loss when it does occur [4]. It can be described in five stages as follows: risk awareness, risk identification, risk assessment, risk management, and re-evaluation [5].

  Risk awareness Top

Over the past several decades, our understanding of the origin of anesthetic risk has changed, from individual-based, to operating room-based, to system-based.

Individual based

Usually, there are many limitations to human performance such as communication problems, stress, prospective memory defect, and fatigue or burnout syndrome. However, use of the term human error well describes what happens in an accident, but does not explain why that particular complication may have occurred. This fundamental inadequacy in the concept of human error led to further analysis of what factors might underlie and facilitate the occurrence of complications [4].

Operating room based

In 1972, Edwards developed a four-component model of human factors [Table 1]. The components, Software, Hardware, Environment, and Liveware gave rise to the acronym SHEL. The fourth component, Liveware, describes 'humans' or 'personnel' [6].
Table 1: The SHEL model of the operating room [4]

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However, although the study of human factors provided an understanding of the scene of a complication, what was not included were other potential components of the event, particularly those from the past that 'set the stage' for the occurrence of an accident [5].

System based

Researchers have been able to move away from the 'traditional' view that the cause of accidents lies with flawed individuals or their flawed interactions with the other components of the human factors model toward a new understanding of accident causation.

One such model [7] describes how complex sociotechnological systems (such as the operating room) are afflicted with two different but complementary types of flaws or failures. The first type, active failures, represents the actions of the human or the operator. These frontline operators often appear to be the principal instigators of system breakdown (this is where the term human error was often applied). Active factors include the patient, anesthetist, and surgeon. Their actions are particularly important when they interact with the other components of the complex system in which they work [7]. The patient's preoperative condition imposes risks [8]. Anesthetic risks are dependent partly on the practitioner's selection, training and experience, and the type of anesthetic to be administered. Operative risk is that which the operation alone poses to any patient such as bleeding and infection, with failure of the procedure to be effective determined partly by the skill of the surgeon and partly by the operation to be performed [2].

Rather than being mere instigators of accidents, the role of these 'active failures' is catalytic, providing many of the local triggering conditions necessary to expose the second type of system flaws. These latent failures are crucial weaknesses: flaws already present or built into the system. Flaws at the structural level may be found within the administration (decision-makers, line management), and staff and equipment (preconditions). Flaws at the procedural level may be found within operational procedures. Flaws at the level of influencing outcome may be found within intrinsic and extrinsic recovery mechanisms (system defenses) [9].

The combination of active failures with latent failures may result in system dysfunction, depending on the degree of 'malignancy' of the resident pathogens (with malignancy defined by the number, complexity, and position of the pathogens in the system). All systems contain some pathogens and all systems are at risk of failing. In addition, the greater the complexity of a system, the greater the number of pathogens and the greater the risk of failing.

Risk identification

Risk identification is a process for identifying specific risks in a particular set of circumstances. This can be either retrospective or prospective [5]. Critical incidents and events may trigger implementation of the Critical Review Policy [Table 2].
Table 2: Critical incidents and events that may trigger implementation of the critical review policy [4]

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Risk assessment and analysis

Once a particular risk has been identified, the magnitude of the risk needs to be assessed to determine the extent and nature of the control measures required to bring the risk within acceptable levels. Two aspects of the risk are assessed: the likelihood of occurrence or recurrence and the most likely outcome should the hazard be realized. A commonly used scale for outcome severity is shown at [Table 3] [5].
Table 3: A commonly used scale for outcome severity [5]

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Other factors or alternative ways of estimating severity are the number of patients involved and the likely cost of litigation.

  Risk management Top

The actions taken aim to reduce an identified hazard to a tolerable risk, that is, a risk that has been reduced to the lowest level possible within available resources. Risk management is usually subdivided into risk 'control' and risk 'financing'. Risk control may be subdivided into risk prevention, avoidance, and reduction. Each of these subdivisions may be considered analogous to the three subdivisions of quality assurance: structure, process, and outcome. Prevention includes review and assessment of personnel, equipment, and environmental aspects of care, whereas avoidance means the elimination of activities that have risks considered too high risk to be acceptable. The third component of risk control includes reduction of risk which means trying to limit damage to prevent future events; from previous implanting polices and procedures for risk control is essential. The scope of the policy should include all surgical patients throughout the preoperative, intraoperative, and postoperative periods. Thus, all patient care areas that might be involved are included: preoperative (preassessment) clinics and units, operating rooms, obstetric suite, accident and emergency unit, recovery unit, intensive therapy unit, and wards [10].

The policy may be triggered by the occurrence of either a 'critical incident' or a 'critical event', defined according to outcome, process, and structure of care [Table 2]. A critical incident is one in which the process of care was not as planned or anticipated, even though outcome of care was acceptable. A critical event is one with a true adverse outcome, such as death or serious bodily harm. In addition, the policy can be triggered by a departmental head or senior administrator, or when medicolegal consequences might be anticipated. Fatal events that may trigger such policies are unexplained deaths, maternal deaths during or following pregnancy or within 10 days of an operative procedure or while under or during recovery from anesthesia. Nonfatal events are unexpected respiratory or cardiac arrest, unexpected major neurological deficits, unexpected major postoperative organ failure, or severe drug or blood reaction [9].


As shown in [Table 4], this policy may consist of four phases, determined by the time of response and the major steps involved [11].
Table 4: Risk management policy [4,11]

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Phase 1

'Phase 1' concurrent with and immediately after the event' involves five steps [11]:

  1. Step 1 - Care: care patient and staff, optimize and consult independent physician.
  2. Step 2 - Isolate: the scene and remove all potentially suspect equipment.
  3. Step 3 - Document: all information facts only.
  4. Step 4 - Inform: and notify patient and family departmental head, director of patient care, senior operating officer.
  5. Step 5 - Debrief and Support: patient and family, identify contact physician, and identify support persons.

Phase 2 (48 h) investigation

Pre-inquiry meeting: Before an inquiry meeting is held, investigation of the scene should be completed and carried out as soon as possible while the 'memory of the case (is) still fresh' [12]. Investigation should be systematic and accurate [13], and is facilitated by drawing up a timeline [14]. Any other information considered pertinent should be reviewed, as should all relevant policies and guidelines.

Inquiry meeting

This committee is chaired by the departmental head or risk manager of the anesthetic department, and includes those involved in the event (anesthetists, surgeons, registrars, nurses, etc.) [15].

The purposes of the meeting are to corroborate facts and to identify all contributory factors: the patient, the anesthetist, the surgeon, other personnel, equipment, the environment, and the system. Members of the committee should be asked for their suggestions as to the development of recommendations to mitigate the recurrence of such an event. Recommendations may be in the form of educational activities or the formation of policies with respect to personnel, equipment, the environment, and the system [15].

Phase 3 (72 h) reporting

The risk manager should prepare a report, which should start with the minutes of the inquiry meeting (these should include the date and time of the meeting, those in attendance, and a summary of the discussion). Then, a narrative summary of the case and a copy of the timeline should follow. A description should be given of any special investigations and their results, for example examination of gas pipelines. The contributory factors, and how they influenced the outcome, should be listed. Statements should be made as to the presence or absence of breach of standard of care and the presence or absence of appropriate policies or guidelines. The final form of the recommendations developed by the inquiry committee should be submitted, with a plan for their implementation and monitoring. The report should then be presented to the hospital or health authority risk manager [4].

Phase 4 (long term) prevention of future recurrence

Hospital and regional health authority have the responsibility for ensuring that recommendations are implemented [4].


Risks should be reviewed and reassessed regularly to ensure that the assessments remain accurate and new risks have not been introduced by controls intended to reduce risk. Any new practice, service activity, or procedure should prompt a clinical risk assessment to ensure that appropriate controls and salvage strategies are implemented. It is essential to embed within the organization the routine collection of relevant information, analysis, and feedback with appropriate actions to relevant staff and to promote a just blame and safety culture [5].

  Conclusion Top

Anesthesia-related adverse events still occur frequently, causing relevant suffering and costs for patients and anesthesiologists. If applied correctly and not limited to compelling statistics, risk management can be a powerful, highly beneficial aid to our practice.

  Acknowledgements Top

Conflicts of interest

None declared.

  References Top

1.Cabrini L, Levati A. Risk management in anesthesia. Minerva Anestesiol 2009; 75:638-643.  Back to cited text no. 1
2.Eichhorn JH. Risk management in anesthesia. Rev Mex Anest 1997; 20:84-90.  Back to cited text no. 2
3.Staendera SE, Mahajan RP. Anesthesia and patient safety: have we reached our limits? Curr Opin Anaesthesiol 2011; 24:349-353.  Back to cited text no. 3
4.Davies JM. Risk assessment and risk management in anesthesia. Baillière′s Clinical Anaesthesiology 1996; 10:357-372.  Back to cited text no. 4
5.Bould MD, Hunter D, Haxby EJ. Clinical risk management in anesthesia. Contin Educ Anaesth Crit Care Pain 2006; 6:240-243.  Back to cited text no. 5
6.Hawkins FH. Human factors in flight. London: Gower Technical Press; 1987.  Back to cited text no. 6
7.Reason J. The contribution of latent failures to the breakdown of complex systems. Philos Trans R Soc Lond B Biol Sci 1990; B327:475-484.  Back to cited text no. 7
8.Davies JM. Complications after general anesthesia. In: Ninamo WS, Rowbotham DJ, Smith G, (editors). Anesthesia. Oxford: Blackwell Scientific; 1994. 758-787.  Back to cited text no. 8
9.Eagle CJ, Davies JM, Reason CJ. Accident analysis of large-scale technological disasters applied to an anesthetic complication. Can J Anaesth 1992; 39:118-122.  Back to cited text no. 9
10.Ogram D. The 1991 CCHFA (Canadian Council on Health Facilities Accreditation) standards and risk management. Can J Med Technol 1991; 53:189-190.  Back to cited text no. 10
11.Davies JM. On-site risk management. Can J Anaesth 1991; 38:1029-1030.  Back to cited text no. 11
12.Gaba DM, Maxwell M, DeAnda A. Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology 1987; 66:670-676.  Back to cited text no. 12
13.Armstrong JN, Davies JM. A systematic method for the investigation of anesthetic accidents. Can J Anaesth 1991; 38:1033-1035.  Back to cited text no. 13
14.Caplan RA. In-depth analysis of anesthetic mistakes: tools and techniques. Int Anesthesiol Clin 1989; 27:153-160.  Back to cited text no. 14
15.Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia Crisis Resource Management Training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992; 63:763-770.  Back to cited text no. 15


  [Table 1], [Table 2], [Table 3], [Table 4]

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