ASA, American Society of Anesthesiologists; OR, operating room.

1. The key factors in the prevention of patient injury are vigilance, up-to-date knowledge, and adequate monitoring. The Web site of the American Society of Anesthesiologists (ASA) may be reviewed for any changes in ASA Standards of Practice as well as a review of ASA guidelines.

2. Perioperative use of the surgical safety checklist has reduced surgical complications and mortality (Table 4-3).

C. Informed consent regarding anesthesia should be documented along with a note in the patient’s chart that the risks of anesthesia and alternatives were discussed. Effective disclosure can improve doctor–patient relations, facilitate better understanding of systems, and potentially decrease medical malpractice costs.

D. Record Keeping. The anesthesia record should be as accurate, complete, and as neat as possible. The use of automated anesthesia records may be helpful in the defense of malpractice cases.

E. What to Do After an Adverse Event

1. If a critical incident occurs during the conduct of an anesthetic, it is helpful to write a note in the patient’s medical record describing the event, the drugs used, the time sequence, and who was present.

2. If anesthetic complications occur, the anesthesiologist should be honest with both the patient and family about the cause. A formal apology should be issued if the unanticipated outcome is the result of an error or system failure. Some states have laws mandating disclosure of serious adverse events to patients (disclosure discussions may be prohibited as evidence in malpractice litigation).

3. Whenever an anesthetic complication becomes apparent after surgery, appropriate consultation should be obtained, and the department or institutional risk management group should be notified. If the complication is likely to lead to prolonged hospitalization or permanent injury, the liability insurance carrier should be notified.

F. Special Circumstances: “Do Not Attempt Resuscitation” and Jehovah’s Witnesses. Patients have well-established rights, and among them is the right to refuse specific treatments.

1. Do Not Attempt Resuscitation (DNAR). When a patient with DNAR status present for anesthesia care, it is important to discuss this with the patient or patient’s surrogate to clarify the patient’s intentions. In many hospitals, the institutional policy is to suspend the DNAR order during the perioperative period because the cause of cardiac arrest may be easily identified and treated during surgery.

2. Jehovah’s Witnesses. The administration of blood or blood products may be refused because of a belief that the afterlife is forbidden if they receive blood.

3. As a general rule, physicians are not obligated to treat all patients who seek treatment in elective situations.

a. Emergency medical care imposes greater constraints on the treating physician because there is limited to no opportunity to provide continuity of care in a life-threatening situation without the initial physician’s continued involvement.

b. Exceptions to patients’ rights include parturients and adults who are the sole support of minor children. In these instances, it may be necessary to seek a court order to proceed with a refused medical therapy such as a blood transfusion.

G. National Practitioner Data Bank requires notification requires notification of (1) medical malpractice payments, (2) license actions by medical boards, (3) license actions by states, and (4) negative actions or findings by a peer review organization or private accreditation entity.

III. QUALITY IMPROVEMENT AND PATIENT SAFETY IN ANESTHESIA. It is generally accepted that attention to quality improves patient safety and satisfaction with anesthesia care. There may be an emphasis on patient safety and the prevention of harm from medical care. Quality improvement programs are generally guided by requirements of The Joint Commission (JC), which accredits hospitals and health care organizations.

A. Structure, Process, and Outcome: The Building Blocks of Quality

1. Although quality of care is difficult to define, it is generally accepted that it is composed of three components: structure (setting in which care is provided), process of care (preanesthetic evaluation plus continual attendance and monitoring during anesthesia), and outcome. A quality improvement program focuses on measuring and improving these basic components of care.

2. Continuous quality improvement (CQI) focuses on system errors, which are controllable and solvable, as opposed to random errors, which are difficult to prevent. A CQI program may focus on undesirable outcomes as a way of identifying opportunities for improvement in the structure and process of care. Peer review is critical to this process.

B. Difficulty of Outcome Measurement in Anesthesia

1. Improvement in quality of care is often measured by a decrease in the rate of adverse outcomes.

2. Adverse outcomes are rare in anesthesia, making measurement of improvement difficult. To complement outcome measurements, anesthesia CQI programs can focus on critical incidents (events that cause or have the potential to cause patient injury if not noticed or corrected in a timely manner [ventilator disconnect]), sentinel events, and human errors [inevitable yet potentially preventable by appropriate system safeguards].

C. Joint Commission Requirements for Quality Improvement

1. Anesthesia care is an important function of patient care that has been identified by the JC. It is important that policies and procedures for administration of anesthesia be consistent in all locations within the hospital.

2. The JC has adopted and annually updates patient safety goals for accredited organizations (Table 4-4).

3. The JC’s accreditation visits are unannounced and involve the inspector observing patient care to confirm that safe practices (timely administration of antibiotics, proper labeling of all syringes on the anesthesia cart) are routinely implemented.

4. The JC requires that all sentinel events (i.e., unexpected occurrences involving death or serious physical or psychological injury) undergo root cause analysis.

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Anesthesia for Laparoscopic and Robotic Surgeries Ambulatory Anesthesia Preoperative Patient Assessment and Management The Liver: Surgery and Anesthesia Neonatal Anesthesia Autonomic Nervous System: Physiology and Pharmacology

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