Quality in Health Care 1995;4:1 15-121

Clinical risk management in anaesthesia

Jonathan Secker Walker, Michael Wilson

Health care is a risky business; clinical riskmanagement is a system which helps reduceavoidable risk to patients and staff, whichenhances the quality of care for future patientsby identifying areas of risk and by changingpractice, and which at the same time protectsthe financial assets of a healthcare institution.Clinical risk management has been defined byRunciman as the cost effective reduction of riskto levels perceived to be acceptable to society.'

What are the risks associated withanaesthesia?General anaesthesia entails keeping the patientunconscious, providing adequate analgesia,and relaxing the patient's muscles to facilitatesurgery. All these processes may, to a greateror lesser degree depending on the depth ofanaesthesia, deprive patients of their respiratoryreflexes. Hence safeguarding the patient'sairway from the mouth to the lungs and main-taining adequate ventilation is a major com-

ponent of a general anaesthetic procedure.According to Utting, the commonest reason

for anaesthetists in the United Kingdomcontacting the Medical Defence Union, com-

prising 52% of its reports, was because theyhad damaged their patient's teeth duringanaesthesia.2 More recently, Aitkenhead,analysed the 150 claims to the union between1989 and 1990 and listed the pattern of moreserious injuries leading to actual or threatenedlitigation (table).

Allegations of painful awareness, accountingfor about 12% of this review series,3 continueto be an appreciable problem, perhaps becausepress coverage has alerted patients to itspossibility. The incidence of painful awareness

has been reported to be of the order of 0-01%during elective general surgery.4 Among 2000anaesthetic incident reports Osborne et alfound 16 cases of awareness, six due to a

syringe swap in which the muscle relaxantsuxamethonium was given to a consciouspatient and three due to low concentrations ofvolatile agents; in the remaining seven cases no

cause was obvious.5 Painful awareness is

Department ofSurgery,Rayne Institute,University CollegeLondon Medical School,LondonJonathan Secker Walker,honorary senior lecturer

Royal United Hospital,Bath BA1 3NGMichael Wilson,consultant anaesthetistCorrespondence to:Dr Secker Walker

Proportion of serious injuries leading to actual or threatenedlitigation among 150 claims, 1989-90

Brain or spinal cord damage 23-8Death in postoperative period 17-0Awareness during general anaesthesia 12-2Death during anaesthesia 11-6Pain during regional anaesthesia 7-5Peripheral nerve damage 4-1Fetal death 1-4Suxamethonium pains 1-4Miscellaneous injuries 21-1

(fractured ribs, tissued infusions,pneumothorax and laryngeal damage)

usually accompanied by hypertension andtachycardia, and such signs should alert theanaesthetist to the possibility that the patientis not fully anaesthetised. Such experiences can

lead to post traumatic stress syndrome forpatients, for whom early recognition andcounselling are advisable. Denial by theanaesthetist of the possibility of awareness

during the postoperative visit usually makesthe situation considerably worse. In a reviewof five recent legal cases involving plaintiffscomplaining of being awake and in pain duringsome part of the operation settlements for theplaintiff ranged from £15 000 to £100 0O0.6The commonest causes related to insufficientinduction agent (thiopentone), no volatileagent being given, no hyperventilation and lowpercentages of nitrous oxide, and the error ofnot checking that the vaporiser is full.The immediate postoperative period is

potentially dangerous for anaesthetised patients:of the deaths and cases of brain damage inAitkenhead's review no less than 47-8%occurred in the postoperative period.3 Cooperet al used collections of critical incidents inanaesthesia to investigate human errors andequipment failure.7 They showed that 82% ofpreventable incidents involved human error

and only 14% equipment failure. However, theproportion for human error is increased bymany breathing system disconnections, whichmight equally well have been classed as

equipment failure. Evidently, poor equipmentdesign was partially involved with many of thehuman errors. Cooper et al also described the10 commonest critical incidents, ofwhich 70%were related to failure to ventilate the lungswith oxygen (box). Webb et al in an analysisof 2000 incidents showed that the fivecommonest incidents, comprising 40% ofthe total, were all related to ventilatoryproblems,9 and the same pattern applied torecovery wards, in which over two thirds ofcritical incidents related to ventilation ofpatients.'0

Commonest critical incidents inanaesthesiaBreathing circuit disconnectionInadequate gas flowsSyringe swapGas supply problemsDisconnected intravenous lineMalfunction of laryngoscopePremature extubationCircuit misconnectionHypovolaemiaProblem with endotracheal tubeSource: Cooper et al1

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Frequency of risksReliable estimates of the frequency of risk aredifficult to obtain, since although death isabsolute and measurable, those deaths whosecause is considered to be totally or partially dueto anaesthesia are often a subject of debate andthe arguments based on imperfect information.Furthermore, the numerator is small and thereis often uncertainty about the accuracy of thedenominator. Therefore the many differingreported rates of mortality and anaesthesiashould be accepted with caution. The report ofthe Confidential Enquiry into PerioperativeDeaths (CEPOD), for example, indicates thatonly three deaths out of nearly half a millionwere entirely due to anaesthesia whereasanaesthesia was partly implicated in one deathin 1300 deaths."The reported incidence of complications in

anaesthesia depends on definitions, classifi-cation, and the enthusiasm of the reporters.The risks change from year to year and countryto country as anaesthetic practice alters andadapts. Various values for risk have beenreported'2 '3 and it is probably less than 0 5%.What matters most is the situation in individualhospitals at a particular time.

Reducing riskRisk may be reduced by three strategies, as

follows.* Identifying the causes of accidents and errors

and developing preventive measures

* Adopting procedures associated with lessrisk

* Using monitors to give early warning oftrouble, thus allowing the anaesthetist torecover the situation before harm befalls thepatient.

IDENTIFYING CAUSES OF ACCIDENTS AND

ERRORS AND DEVELOPING PREVENTIVE

MEASURES

Accidents may be caused by human error,equipment failure, and some kinds oforganizational failure.

Human error

An anaesthetist has to obtain informationabout the physiological state of the patient andthe progress of the anaesthetic from observingthe patient, the monitors, and the anaestheticmachine, the information from which is usedto make decisions about the anaesthetic. Anyrequired change will necessitate an action, suchas adjusting a control, which must be correctlyexecuted to achieve the desired end. Conse-quently, human errors may occur during theobservation (input), decision making, or action(output) stages.Input and output errors can be minimised by

good equipment design. Advances in the designof monitors have eliminated many subjectiveerrors and introduced a range of importantmeasurements not previously available. A new

generation of anaesthetic monitors usingcomputer technology can integrate and displayphysiological information and raise alarmswhen predetermined limits are transgressed.The overall aim is to provide information that

is easily assimilated, thus reducing the risk ofmental overload; unfortunately false alarms arestill very common with current monitoringequipment.'4 This usually means repeating theobservation or acquiring other confirmatoryevidence, or both,"5 16 by direct observation ofthe patient or from other monitors.

Traditionally, constant vigilance is expectedof the anaesthetist,'6 1' yet it is clear thatcontinuously maintaining total alertness andvigilance is not possible, as confirmed bycritical incident studies."' Well designed equip-ment and physiological monitors trigger areturn to total vigilance at appropriate times.Critical incident studies also suggest that theremay be an advantage in changing anaesthetistsduring a long procedure.'8When making decisions the anaesthetist has

to decide not only whether something is wrongbut also why. The monitors indicate which vitalsigns are abnormal, but the anaesthetist mustpiece the various items of information togetherand choose a hypothesis that will lead to thecorrect action. Often the anaesthetist willfollow some, perhaps unconscious, mental ruleand select the most common explanation thatmatches the situation. Known as frequencygambling,'9 this approach usually provides acorrect solution, although not always.20 Abstractreasoning will be required to solve a novelproblem. This knowledge based behaviour isslower and requires more effort. Anaesthetistsneed to be taught to question their decisionsbecause clinging to false hypotheses or aninappropriate rule is a well known cause ofaccidents. This dangerous form of "keyhole"thinkingly 21 22 is especially common inparticular circumstances,23 when disastrousdecisions may be adhered to, irrationally andtenaciously, despite conflicting evidence.Anaesthetists need to be aware of this dangerand must be prepared to listen to otheropinions. The House of Lords recently uphelda conviction for manslaughter on the groundsthat it constituted gross negligence (and hencea criminal offence) for an anaesthetist to havefailed to recognise a ventilator circuit dis-connection which led to a patient's death.

EquipmentfailureSince faulty equipment rarely causes seriousaccidentS21 24 25 or critical incidents8 9 26 thereis the risk of complacency. Disconnections inthe breathing systems carrying oxygen andanaesthetic to the patient are frequent and ifundetected can cause death.8 9 26-28 Butlatterly, with the increasing use of disposablebreathing systems, this incident seems lesscommon. None the less some form of dis-connection warning device is essential.

Various national and international standardsorganizations have taken an important lead inimproving equipment safety.27 In the UnitedKingdom the Medical Devices Directorate24has an important role in developing thesestandards, evaluating equipment, and approvingmanufacturers, also being responsible forinvestigating accidents associated with medicaldevices and issuing hazard notices and safetyaction bulletins to warn other users.

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Risk management in anaesthesia

OrganisationalfailureHospitals should provide a safe environmentfor anaesthesia with well designed and equippedanaesthetic, operating, and recovery rooms.

The importance of skilled help - operatingdepartment assistants or anaesthetic nurses,

recovery nurses, and more senior anaesthetichelp (when required)-has already beenemphasised in many mortality surveys.11 25 29

Hospital managers require proof that invest-ment in safety is worthwhile; however, as

Brahams pointed out, those who plead lack ofcash may regret their decision when a case

comes before the courts.30Too few appropriate staff, poor depart-

mental organisation, or insensitive manage-

ment may lead to fatigue, lack of sleep, hunger,frustration, excessive workload, and poor

morale, all of which probably decrease per-

formance.'6 Although experience and commonsense support this view, satisfactory experi-mental evidence is hard to find and in surveys

the number of incidents attributed to thesefactors is few.9 11 26

ADOPTING PROCEDURES ASSOCIATED WITH LESS

RISK

Whenever possible, adopting techniques thatavoid known risks has obvious advantages.For example, the complications of failedintubation (which include death) will not ariseif anaesthetic techniques are chosen which donot require tracheal intubation. Furthermore,it is wise to choose techniques that are "failsafe"23; a spontaneously breathing patient willsurvive a disconnection whereas a paralysedpatient may die.

MONITORING AND RECOVERY PROCEDURES

When something does go wrong during an

anaesthetic a chain of events is initiated whichmay lead to harm and, in an extreme situation,to cardiac arrest, an event which could bedetected by a single monitor (an electro-cardiograph). However, investing in severalmonitors that can detect different stages inthe propagation of an incident is more sensible(a disconnected ventilator may be detected, forexample, by falls in inspiratory pressure, tidalvolume, end tidal partial pressure of carbondioxide, and oxygen saturation before theelectrocardiogram becomes flat). Differenttypes of monitor cover a range of possibleincidents. Consequently if an incident isdetected early enough harm may be avoided bythe speedy implementation of some recoveryprocedure. For example, Gaba et al discussingtechniques to interrupt evolving anaestheticaccidents, pointed out that 93% of the criticalincidents recorded by Cooper et al8 were

successfully managed.'5 Early detection allowsmore time to initiate recovery procedures andreduces the likelihood of an incident leadingto harm.'5 3' Factors affecting the recoverysequence have been analysed by Galletly andMushet.32Prompt corrective action may not allow

much time for thought and some incidents mayoccur so rarely that little experience is gainedin handling them. Taking the appropriate

recovery action is essential because an

incorrect response may precipitate anotherincident,2' which may have even more seriousconsequences. For these reasons there ismuch to recommend having readily available a

set of Anaesthesia Action Plans.33 Such a

strategy represents a shift to rule basedbehaviour rather than the slower knowledgebased behaviour. Ideally, decisions aboutemergency procedures should be made inadvance, at leisure, with the benefit ofcollective wisdom, and incorporated into thedepartment's standard operating procedures.Both DeAnda and Gaba20 21 and Schwid andO'Donnell22 using an anaesthesia simulatorprovided a valuable training tool and alsoinsight into the way anaesthetists deal withcritical incidents. Proceeding further, Gabaet al have encouraged specific training in crisismanagement in anaesthesia.34

Managing riskA risk management programme in anaes-

thesia should aim at identifying areas of riskbefore a patient is harmed and it needs tocontinuously review, and where necessaryimprove, various aspects of anaesthesiadelivery (box).

EQUIPMENT AND MONITORING POLICIES

Many departments of anaesthesia have agreedpolicies for purchasing equipment and decidingthe appropriate level of monitoring. Con-formity of equipment and monitors decreasesthe risk of junior anaesthetists being con-

fronted with unfamiliar tools in the middle ofthe night. Furthermore, a sensible budgetaryapproach is required to ensure regular servicingof the equipment and a rolling replacementprogramme, which, if not performed, may leadto patient harm or sudden cancellation ofoperating lists resulting in inconvenience topatients and loss of revenue to the provider.Enlightened trust status may encourage suchbudget management, which was usually lackingunder previous administrations. Aitkenheadestimated that an anaesthetic machine costing£25 000 discounted over a ten year periodwould add £4 to the cost of each operation35;anaesthetic work stations that include fullintegral monitoring and computerised recordkeeping cost twice as much, but even thiswould be a tiny proportion of an operation's

Aspects of delivery of anaesthesia1 Equipment and monitoring policies2 Adverse incident reporting systems3 Medical records4 Communication and informed consent5 Operating theatre procedures6 Supervision of junior staff and locums7 Locums8 Recovery room9 Continuing medical education, maintenance

of skills10 Consideration of risks associated with new

techniques11 Damage limitation

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total cost. There is increasing evidence toconvince managers that compliance withminimum monitoring standards does improvethe safety of anaesthesia.36 The Australianincident monitoring study of 2000 incidentsshowed that the role of monitors in aidingpatient safety was thoroughly vindicated.37Tinker et al reviewed 1175 anaesthetic relatedmalpractice claims between 1974 and 198838:among the 1097 claims with sufficient infor-mation available for the reviewers to make ajudgement, 31 5% of negative outcomes - theworst rated - would have been prevented byadditional monitors. Pulse oximetry andcapnometry were judged the most usefulmonitors. Since minimal standards foranaesthesia have been adopted in the UnitedStates the cost of malpractice claims againstanaesthesiologists has decreased by about twothirds and in the Harvard group of hospitalsinsurance premiums for anaesthesiologistshave fallen by 40% and are now less than fora urologist or gynaecologist.39A common cause of incidents is failure to

understand how to use the equipment. 926 40This is no surprise; one survey disclosed that48% of anaesthetists use new equipmentwithout reading the instruction manual.4'Some manuals are ignored because they areexcessively long and poorly written. Some-times, because of urgency or other force ofcircumstance there is no opportunity fortraining, and it is regrettable that hospitalscommonly fail to ensure that sufficient time isdevoted to training.Another common cause of incidents is failure

to check equipment before use8 9 26 40 42:between 30% and 41% of anaesthetistsperform no checks and, of those who do, fewfollow the guidelines of the Association ofAnaesthetists.43 Seemingly the risk of seriousinjury is perceived as being so small that theeffort is not seen to be justified, a viewstrengthened by the knowledge that trivialequipment related incidents are a dailyoccurrence which are almost always detectedand rectified - a very dangerous attitude.The anaesthetist is held legally responsible

for the functioning of the equipment he or sheuses and the drugs given. Apart from thechecks of the machine and monitors, otherdanger areas that need special attention areunlabelled syringes, running repairs to equip-ment (especially components of the airway),drugs drawn up by other staff, and thevaporiser that looks full but is actually empty,which is one cause of painful awareness. Allnew staff and locums should receive trainingon the equipment used by the department andshould be provided with protocols for equip-ment checks.

Procedures to ensure that hazard warningnotices and safety action bulletins issued byMedical Devices Directorate are received andread by relevant staff are the responsibility ofthe hospital managers and the clinical director.In a recent survey in southwest England only66% of consultant anaesthetists and 33%/o ofjunior anaesthetists were moderately confidentthat they had seen relevant notices.4'

ADVERSE INCIDENT REPORTING SYSTEMSAn integral part of any risk management pro-gramme is the reporting of adverse incidentssince the collection and interpretation of suchdata allow patterns of particular or repeatedevents to be identified. A suitable system willfacilitate the mapping of the distribution ofincidents within the hospital and is describedin greater detail by Lindgren et al.43a Althoughcomplete computerised hospital adverseincident reporting systems are still fairlyuncommon in the United Kingdom,anaesthetic audit systems have been recordingcritical incidents and complications in manyhospitals for some years. To be of use, seriousor repeated incidents must be investigated andrecommendations made to reduce the likeli-hood of recurrence. The Australian incidentmonitoring study (AIMS) recommends that anon-culpable culture that encourages reportingof critical incidents is essential if the fullpotential of incident analysis as a means ofidentifying risk is to be realised and that thisshould include accepting anonymous reports.44The relation between hospital wide adverseincident reports and critical incident moni-toring in anaesthesia needs to be agreed toavoid unnecessary data collection; incidents inwhich patients may have suffered actual harmshould always be reported to the central riskmanagement system.

MEDICAL RECORDSThe risk of litigation may be reduced by main-taining high quality anaesthetic records. If theplaintiff has been granted legal aid the hospitalwill have to pay its own costs of a court caseeven when it wins. In the High Court this mayamount to C100 000. Properly kept anaestheticrecords will reduce the chance of the expertwitness for the plaintiff, when reviewing thenotes, alleging that as a matter of probability(without evidence to the contrary) the cause of,say, brain damage was a hypoxic episode andmay prevent the case coming to court.Meticulous notes detailing drug doses andvapour concentrations may help to defendagainst allegations of awareness.44a The develop-ment of modern complete monitoring systemsallows continuous printouts of informationmonitored, with the ability for the anaesthetistto mark drugs and events on the same chart.These printouts provide valuable evidence ofexactly what took place at what time, but it isimportant to note artifacts and add anynecessary explanation.

COMMUNICATION AND INFORMED CONSENTGood communication with patients is a crucialpart of clinical practice and one of the mosteffective means of preventing litigation whenpatients believe that something has gonewrong. Doctors who seem hurried anduninterested are at risk of being sued even ifthey practice good quality medicine.45 For theanaesthetist this communication needs tostart with the preoperative visit. Furthermore,patients now expect to give "informed"consent to the procedures carried out. LordBridge, considering the case of Mrs Sidaway

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versus the Board of Governors of the BethlemRoyal Hospital in the House of Lords, statedin his judgement, "When specifically questionedby a patient of apparently sound mind aboutrisks involved in a particular treatment pro-posed, a doctor's duty must, in my opinion, beto answer both truthfully and as fully as thequestioner requires."46 Lord Scarman in aminority judgement in the same case felt thatthe doctor should be liable "where the risk issuch that in the court's view a prudent personin the patient's situation would have regardedit as significant."46 There have recently beenincreasing numbers of legal cases concerninginformed consent, many of which have beenwon by the plaintiff.

In view of the high incidence of complaintsto the Medical Defence Union it is prudent towarn patients about the possibility of damageto their teeth, particularly to teeth that arealready loose and in patients with capped orcrowned teeth. Similarly, if regional analgesiais proposed the possibility ofpain or discomfort(accounting for 7 5% of claims to the MedicalDefence Union) should be discussed andthe patient reassured about the action theanaesthetist would take. If the patient isclearly unhappy at the prospect and thereis no strong contraindication for generalanaesthesia it is probably wiser to opt for ageneral anaesthetic. Consent for the use ofsuppositories for postoperative analgesiashould always be sought from the patient pre-operatively.47 If general anaesthesia with con-current regional analgesia is proposed it isimportant to explain this to the patient (or theirparent): a patient expecting general anaesthesiawho in addition suffers an inadvertent spinaltap or neurological damage is likely to feelupset and angry. A report of the preoperativevisit and the issues discussed should always bemade in the patient's notes.

OPERATING THEATRE PROCEDURES

Each operating theatre should have strictprocedures for checking the patient, theintended operation, and the consent form. Theoperating list should be clearly displayed withthe patients' names, hospital numbers, andintended operation. The order of the operatinglist should be altered only for emergencies andpatients should be accompanied by their notes,any relevant radiographs or electrocardio-grams, and results of blood tests. Skilled helpfor the anaesthetist should be available through-out 24 hours." 25 29 Good operating theatreprocedures should ensure that trained staffroutinely protect patients against injury to eyes,nerves, and skin and from diathermy burns. Inaddition, training for staff in lifting andhandling patients is an important safeguardagainst back injury, a common cause of staffsickness which may lead staff to sue theiremployer.

SUPERVISION OF JUNIOR STAFF

Failure to supervise junior anaesthetists is acommon factor in anaesthetic accidents.Reports by Lunn and Mushin48 and the laterCEPOD reports" 25 indicate that perioperative

mortality is to some degree related to thesupervision of trainees in anaesthesia, especiallyin very sick or elderly patients or patientsadmitted as emergencies. Cooper showed thatlack of supervision was the single mostcommonly associated factor in anaestheticmishaps7 and Gannon that inadequate super-vision was a factor in 32% of anaestheticdeaths.49 The CEPOD report of 1987recommended that a consultant should beresponsible for all elective lists." Medical auditdatabases can provide useful information as tothe degree of supervision and types of casesthat juniors are undertaking, which can also beused for their training logbook.

Clinical directors of departments of anaes-thesia are responsible for ensuring that theservice provided for each operating list is givenby appropriately qualified anaesthetists and thatjunior staff are aware of guidelines and rules,especially when to call for help. A commoncause for concern is lack of induction courses forstaff (especially locums) joining departments.Training of young anaesthetists should empha-sise the value of "safe" anaesthetic practice inreducing risk to the patient and of being alertto the possibility of awareness.

LOCUM COVER

Locums are commonly involved in medicolegalproblems. Often hired in haste to fill gaps instaffing cover, frequently for a weekend, theircredentials may not be fully checked. Somedoctors remain locums because of difficulty insecuring a recognised post and tend to passfrom one short term job to another. They mayencounter considerable difficulty in keepingtheir postgraduate training up to date. It isimportant that the consultant responsible forobtaining locums vets their qualifications andexperience, and he or she must make checkswith a previous employer.50 Too often this taskis left to a very junior medical staffing officer.The degree to which junior staff locums maybe left unsupervised should be decided by theclinical director and made explicit to theperson responsible for drawing up the rota.Special care needs to be taken with locumconsultants who will be left without supervision.

RECOVERY ROOMS

The use of recovery rooms, provided they areappropriately staffed and equipped, shouldlead to fewer accidents occurring in theimmediate postoperative period, and recoveryrooms should be available to receive all post-operative patients 24 hours a day." 25 Theprecipitate return of a patient to a surgicalward, where the degree of patient supervisionmay be much less, owing to inadequate staffingand the consequences of skill mix reviews inthe interests of economy, does place sick post-operative patients at risk of complicationsgoing unrecognised, and the anaesthetist maybe criticised for allowing discharge to the wardtoo early. High dependency units or the post-anaesthetic recovery (PAR) rooms used inmany North American-hospitals, where patientsstay for considerable periods after majorsurgery before returning to the ward, have

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much to commend them. They have the addedadvantage of allocation of an anesthetist to thefacility, enabling cardiorespiratory instability tobe treated and proper pain relief maintained,and in addition, postoperative complicationsare more likely to be accurately recorded thanin the ward.

(CON INUING EDICAlI EDUCAITIONThe importance of postgraduate education andtraining has been a feature in published workrelated to adverse events in anaesthesia. A riskmanagement programme should keep underreview the opportunities and funding availableto staff for continuing education.The royal colleges are all developing con-

tinuing medical education schemes for con-sultants, requiring a set number of hours ofapproved study in order to retain the right toteach. It is not clear, at this point, whatsanctions will apply for failure to comply.The current position as regards the Calman

recommendations for staff in training'' is alsounclear. The proposals for the hours that juniordoctors may work; new style training posts,meaning significant reductions in the avail-ability and numbers of junior staff; an officialceiling on the numbers of non-consultantcareer grades; and a shortage of availablepotential consultants will all tend to makeanaesthetic staffing increasingly difficult tomaintain and hamper opportunities for timeallowed for junior staff to attend courses forspecialist diplomas, in house postgraduatemeetings, and training in practical anaesthesia.The job description and contract of con-

sultants in the National Health Service donot encourage flexibility of interpretation.Accreditation entails demonstrating broadskills across the anaesthetic spectrum. How-ever, after appointment to a consultant post ananaesthetist may be contractually required tocover the same operation lists for years makingit difficult to maintain skills in subspecialitieswhich require constant practice, especially insmall children, thoracic and vascular surgery,emergency neurosurgery, neonatal care, andcardiac surgery. Many such cases are referredto regional centres but a patient reasonablyexpects that the anaesthetist is appropriatelyskilful for their particular condition. Clinicaldirectors bear the responsibility of ensuringthat operating sessions are covered by doctorswith appropriate specialist competence. Fre-quently on call work is split into subspecialityrotas such as those for small children, obstetrics,and intensive care. Postgraduate training shouldbe available to consultants to promote theirmaintenance of necessary experience and skills,including advanced trauma (ATLS) and cardiaclife support (ACLS) courses. This may requireflexibility in the weekly timetable and, in smallerhospitals, the opportunity to practise in largerpostgraduate centres.

EVAI UATI ING RISKS ASSOCIATED WITH NEWI ECHNIQUES

Anaesthesia has to adapt to changing surgicalrequirements, and hazards that may bepeculiar to a new operation or anaesthetic

technique need to be considered. In the earlydays of laparoscopy patients were occasionallyanaesthetised solely with a mask and spon-taneous ventilation, with inevitably seriousconsequences. Laser surgery to the lowerrespiratory tract to relieve the dyspnoea ofbronchial tumour is a procedure potentiallyfraught with hazard, and laparoscopiccholecystectomy has cardiovascular effects onolder patients under general anaesthesia thatmight not have been expected>." Suchprocedures need consideration, discussion,and evaluation by senior anaesthetists before aprotocol is developed and junior staff leftunsupervised.

DAMAGEI LL1IMIATIONEven in the best hospitals accidents will con-tinue to happen, and the organisation needs todevelop policy as to how to cope with a patientwho has been harmed and who is angry or withthe relatives. Denial and secrecy usually lead toan increasingly vindictive victim whereashonesty, discussion, and offers of support maxdefuse the situation before lawyers becomeinvolved.

Patients who have suffered anaesthetic aware-ness need counselling and understanding, andit is essential that nurses in whom the patientmav confide always inform the anaesthetistinvolved as soon as possible.44

Admitting to an accident need not auto-matically include admission of any negligence.Patients are often very anxious that their badexperience will not be suffered by others andseek reassurance that the hospital has learntfrom the event. Early support for the patient bystaff mature enough to deal with the situationis important, as is support for the doctor ornurse, who usually feels very deeply about theaccident and whose feelings are all too oftenignored.A recent study suggests that many senior

doctors suffer high levels of stress, both anxietyand depression.' Other studies have foundsimilar problems in junior doctors.54 5 Psycho-logical ill health often leads to excessive alcoholuse or drug dependency. These are conditionswhich are dangerous for patients in any doctorbut can be quickly lethal in an anaesthetist. Toturn a blind eye on a troubled colleague doesno one any good. There are procedures tohelp sick doctors before patients are harmed,in particular the three wise men procedure,the mechanism of which should be clearlyunderstood by all medical and senior nursingstaff. Additionally, professional help for a sickanaesthetist can be provided by the con-fidential Counselling Service for Anaesthetistsbased at the Association of Anaesthetist'sheadquarters.To most anaesthetists the issues discussed

in this chapter will be familiar, and yet inthe hurly-burly of modern hospital life it isoften difficult for the clinical director andhis or her colleagues to find the time to reviewrisk factors regularly and remind and educatenew and current staff about methods toreduce avoidable risk. Such regular review-perhaps three monthly - might become the

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responsibility of a particular consultant andcould, like clinical audit, become a part ofregular postgraduate training programmes inorder to promote a continuing improvement inpatient safety.

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