Professional Practice, Patient Safety, and Quality Improvement
Professional Practice: Standards, Consent, Status, and Team Care
ASA physical status
PS 1 healthy; PS 2 mild systemic disease; PS 3 severe systemic disease that is not incapacitating; PS 4 incapacitating disease with a constant threat to life; PS 5 moribund, not expected to survive without the operation; PS 6 brain-dead organ donor. Add "E" for emergency. Assignment is a physician judgment documented before induction and is not a measure of surgical complexity alone.
Informed consent
Requires discussion of the nature of the planned anesthetic, material risks, benefits, alternatives including no treatment, and the opportunity for questions, with documentation. Exceptions such as emergency and therapeutic privilege are narrow. Minors and incapacitated adults require a surrogate decision-maker following institutional and legal rules.
Standards versus guidelines
Basic monitoring standards for any anesthetic include continuous oxygen analysis, pulse oximetry, capnography, ECG, blood pressure at least every 5 minutes, temperature when clinically significant changes are anticipated, and a qualified anesthesia professional present throughout. Standards are mandatory; guidelines are advisory and should be documented when deliberately not followed.
Team and business practice
Medical direction of up to four anesthetizing locations requires the seven defined steps, including preoperative evaluation, presence during induction and emergence, and post-anesthesia care. Accurate coding and documentation must reflect care actually delivered. Know the framework for handling impaired colleagues, scope-of-practice rules, and protected peer review.
Traps
Believing PS 4 is the most severely ill category (PS 5 is moribund); treating guidelines as mandates; accepting consent from a delirious patient; recording care that was not provided.
Worked example
A 74-year-old with severe COPD, prior myocardial infarction, and Parkinson disease who can climb one flight is ASA PS 3 -- severe disease without incapacity.
Patient Safety and Quality Improvement
Systems thinking
Errors are properties of systems: active failures at the sharp end (a syringe swap) pass through holes in latent defenses (look-alike labels, no barcode scanning, fatigued staff) -- the Swiss cheese model. Human factors engineering reduces reliance on memory through forcing functions, standardization, checklists, read-back, and closed-loop communication.
Named methods
Root cause analysis is retrospective, performed after a sentinel event. Failure mode and effects analysis is prospective, scoring severity x likelihood x detection. PDSA cycles drive iterative change. Run charts and control charts separate common-cause variation (the process itself) from special-cause variation (assignable), and only special cause justifies hunting a specific culprit.
High-yield safety targets
Medication errors and syringe swaps, wrong-site events prevented by verification, marking, and time-out, retained items, alarm fatigue, handoff failures, unplanned extubation, perioperative hypothermia, pressure injury and falls, and postoperative respiratory depression -- respiratory events dominate closed-claims analysis in anesthesia.
Culture and measurement
Psychological safety and speaking up sustain reporting. Just culture distinguishes human error, at-risk behavior, and reckless behavior, responding with consolation, coaching, or discipline respectively. Disclose harm and support second victims. Build balanced measure sets: process, outcome, and balancing measures.
Traps
Choosing root cause analysis when asked for prospective risk assessment; proposing individual retraining when the question asks for a system fix; treating random variation as a trend; assuming more monitoring is always safer.
Worked example
Three unplanned extubations in one month prompt a control chart. If the point exceeds the control limit, or a run of seven or more points occurs, special cause is present and an RCA is warranted; otherwise target the common-cause process with PDSA cycles.