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Critical Incidents in the OR

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Preventing and managing critical incidents in it all too complex?

Increasing medical knowledge, better technology like ventilators with sophisticated functions, standardised procedures and well-trained medical staff – this is anaesthesia today. However, this is just one side of the coin. Time pressure, high workload, increasing paperwork, older and sicker patients, difficult techniques and knowledge that increases exponentially in a complex environment are the other side of the story.

Though mortality due to anaesthesia has declined, critical events still occur with serious consequences for patients, families, clinical staff and organisations.

  • How can the staff working in anaesthesia be supported in this complex environment?
  • What kind of tools are already available to keep track of the developments?
  • Do we need a new safety culture?

Read on to learn more about how the complexity of the anesthesia work environment impacts patient safety, current approaches to dealing with this challenging situation, and how technology can help.

Safe but complex?

While anaesthesia associated mortality has declined markedly over the last decades, the number of critical incidents is still significant. But why is it so difficult to control the occurrence of perioperative critical events? Anaesthesia is not just complicated, but highly complex and tightly coupled.


Safe speciality with demanding challenges?

In anaesthesia, perioperative mortality has declined remarkedly over the last decades1. Factors like availability of sophisticated technology, improved anaesthetic drugs as well as training concepts, guidelines and standardisation have decreased mortality attributable to anaesthesia close to the standards of high reliability organisations like air traffic control2. While 50 years ago, deaths in healthy patients directly caused by anaesthesia were in the range of 1-2 per 10,000 anaesthetic cases, numbers are now closer to 1 per 100,0003. Nevertheless, there are large worldwide differences in these numbers. Even though fatal incidents have markedly decreased in western countries, the number of critical incidents leading to (peri)anaesthetic morbidity are still significant. In the NAP4-report (4th National Audit Project in the UK), the authors calculate the incidence of serious airway complications during general anaesthesia to be (at least) 1 per 22,000 general anaesthetics with aspiration as the major contributor to airway-related morbidity and mortality in anaesthetic practice4.

Safe but complex?

Read our whitepaper and learn why anaesthesia isn’t just complicated, but complex, and how this may impact patient safety.

Concepts for today and tomorrow


In 2010, the Helsinki Declaration on Patient Safety in Anaesthesiology was launched by the European Board of Anaesthesiologists (EBA) in close co-operation with the European Society of Anaesthesiology (ESA). It represented a shared European opinion on what was practical and worth doing to improve patient safety in perioperative care.

However, the past decade made clear: new approaches are necessary to improve patient safety in the challenging work environment of today’s clinical acute care. One of those approaches addresses the concept of Safety-I and Safety-II.

New concepts needed – Is Safety-II the answer?

Safety-I may approach its limits in a complex work environment. Read our whitepaper to learn what impact Safety-II can make.

Helpful tools to answer this challenge

Standards and guidelines provide relevant information for the best treatment options to reduce outdated and inefficient practice. While standards are criteria established by authority that result in best outcomes, guidelines are “practical helpers” that explain how to perform a task. Guidelines and cognitive aids offer the possibility to bundle this enormous amount of knowledge and provide it to clinicians.

All these aids are valuable tools in keeping track of the high demands in healthcare management, and current movements are aimed at integrating the complex dynamic processes. But they are no “silver bullet” when it comes to handling complexity.

Is there actually something like a “silver bullet” for patient safety? It will be clear to everyone that this can only be a rhetorical question. Download the PDF to learn more about what impact e.g. critical incidence reporting systems and simulation training may have in this context

Helpful tools already available today?

Standards are a valid measure to enforce best practices, but they have limitations. Read our whitepaper to learn how cognitive aids and other tools can help improve patient safety already today.

How technology can aid in managing complexity

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The prospects and limitations of technological support

Technical advances during the last decades have contributed to great improvements in patient safety, ranging from the application of ultrasound when placing catheters to new approaches in clinical airway management such as airway algorithms, video laryngoscopy, extubation catheters, and advanced supraglottic airway devices5. The aim of modern anaesthesia workplaces, however, is to support the clinical team to make fast and informed decisions in their complex work environment.

Automated systems decrease the anaesthetist’s workload and the possibility of human error. Even though we see some technologies emerge, the thorough development of these systems will take some time. What can be done already today? How can the anaesthesia staff be supported and what kind of new tools are available? This is not just the focus of the present article but will also be the topic of further articles and reports on this website.

Technology and its impact on patient safety

Read our whitepaper to learn more about how technology can improve patient safety today and in the future, but also what its limitations are.

ESAIC Euroanaesthesia 2021 Symposium: Focus Patient Safety

Watch the clinical lectures held at the Dräger Satellite Symposium at Euroanaesthesia 2021. Focus was on how assistance system can help improve patient safety in anaesthesia.

Value-based anaesthesia

Prof. Javier Garcia Fernandez takes a different view on evidence based medicine and how the concept of value based medicine can help improve patient safety.

Assistance systems – improving patient safety and clinical processes

Prof. Goezde Inan shares her view and research results on how assistance systems can help reduce complexity to improve clinical outcomes while facilitating clinical processes, taking Dräger SmartPilot View as an example.

Get in touch with Dräger


Drägerwerk AG & Co. KGaA

Branch Office
P.O. Box 505108
Dubai, United Arab Emirates

+971 4 42 94 600

F: +971 4 42 94 699

Not all products, features, or services are for sale in all countries. Please contact your local Dräger representative for more information.


1.         Bainbridge, D., Martin, J., Arango, M., Cheng, D., & Evidence-based Peri-operative Clinical Outcomes Research (EPiCOR) Group. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet 380, 1075–1081 (2012).

2.         Staender, S. Safety-II and resilience: the way ahead in patient safety in anaesthesiology. Curr Opin Anaesthesiol 28, 735–739 (2015).

3.         Higham, H. & Baxendale, B. To err is human: use of simulation to enhance training and patient safety in anaesthesia. Br J Anaesth 119, i106–i114 (2017).

4.         Cook, T. M., Woodall, N., Frerk, C., & Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 106, 617–631 (2011).

5.         John Doyle, D., Dahaba, A. A. & LeManach, Y. Advances in anesthesia technology are improving patient care, but many challenges remain. BMC Anesthesiol 18, 39 (2018).