Risk Management for Anesthesiologists

Anesthesia practice often involves complex risk management challenges. This article examines three essential components of risk mitigation in anesthesiology: preoperative assessments, documentation, and effective communication with care team members. Understanding these factors can help anesthesiologists deliver optimal care while reducing professional liability exposure.

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Preoperative assessment
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Conducting a thorough pre-anesthesia assessment is crucial in determining if a patient can safely undergo anesthesia. The American Society of Anesthesiologists (ASA) has adopted basic standards for pre-anesthesia care, which include the following. 


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1. Reviewing the available medical record.
2. Interviewing and performing a focused examination of the patient to:

• Discuss medical history, including previous anesthetic experiences and medical care; and
• Assess those aspects of the patient’s physical condition that might affect decisions regarding perioperative risk and management. 

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3. Ordering and reviewing available tests and consultations as necessary for anesthesia care.
4. Ordering appropriate preoperative medications.
5. Ensuring that consent has been obtained for the anesthesia care.
6. Documenting in the chart that the above has been performed. (1)

Another important part of the preoperative assessment is to consider what resources will be available at the hospital, surgery center, or procedure site to manage complex patients or anesthesia emergencies. The availability of emergency equipment, radiology facilities, lab facilities, and transfer agreements with inpatient facilities are factors to consider.

Additional precautions are required for office-based anesthesia (OBA). Anesthesiologists practicing in office-based settings must assess whether the planned procedure is within the capabilities of the facility; whether the patient is at undue risk for complications and should be referred elsewhere; and whether the procedure duration and complexity allow the patient to recover safely at the office-based practice. 

In addition, anesthesiologists are expected to “satisfactorily investigate areas taken for granted in the hospital or ambulatory surgical facility such as governance, organization, construction and equipment, as well as policies and procedures, including fire, safety, drugs, emergencies, staffing, training and unanticipated patient transfers”. (2)

Some states have addressed OBA in regulations and laws. In Texas, OBA rules define the levels of anesthesia and outline requirements for staffing, monitoring standards, emergency equipment, and more. Certain levels require that both the anesthesia provider and the physician performing the procedure to register with the medical board as OBA providers. (3) Anesthesiologists should be well versed in any state laws that regulate their practice.

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Documentation
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Accurate, complete, and contemporaneous documentation can be your best defense against a malpractice claim or board action. Ideally, anesthesia reports should be completed as soon as possible after a procedure.

Incomplete or late documentation can compromise patient care, as other physicians will not have access to information needed for treatment decisions and continuity of care. From a legal defense perspective, delayed documentation can raise concerns about the accuracy and completeness of the anesthesia record.

Documentation recommendations for anesthesiologists include the following.

Pre-operative documentation

• Document a thorough patient history and preoperative assessment, including details about previous anesthetic complications, difficult airways or sleep apnea, family history of anesthetic reactions, and current medications (including supplements).
• Document the preoperative discussion of risks, benefits, and alternatives, including specific concerns raised by the patient or family members and how these were addressed.

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Intraoperative documentation

• Maintain time-stamped records of all medications administered. Increased use of electronic anesthesia records has facilitated timed documentation of medication administration and patient monitoring. However, this may not be available in all settings (OBA).
• Document vital sign trends throughout the procedure, with special attention to any significant deviations and the interventions performed in response.
• Record airway assessments and management techniques used, including details of any difficult airway encounters and specific equipment or techniques required.
• Note positioning of the patient, including padding and protective measures taken to prevent complications.
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EMR use

• Review and update any auto-generated text (for example, elements of the pre-anesthesia assessment) to ensure accuracy for the specific patient and procedure.
• Include additional free-text documentation when EMR options do not adequately capture important details.
• Complications and critical events
• Document all complications with timing, including the sequence of events, immediate interventions taken, and patient response to those interventions.
• Record all consultations obtained during critical events, including the name of the consultant and specific recommendations received.
• Include objective clinical findings that supported decision-making during complications.
  


Postoperative documentation

• Document emergence from anesthesia, including patient condition and any complications or concerns during emergence.
• Record detailed handoff communication to PACU staff, including specific monitoring requirements and pain management plans.
• Note any postoperative visits, including assessment of anesthetic complications and follow-up plans for any intraoperative events.

Communication and collaboration with colleagues

Effective communication is fundamental to risk management in anesthesiology. The following communication strategies can help enhance care team performance, improve patient safety, and reduce the risk of adverse events.

Communication with surgeons and OR staff

• Participate in any preoperative briefings or “time-outs” with the surgical team. Discuss any risk factors or critical issues for each case.
• Establish clear expectations for communication during critical phases of the procedure.
• Announce critical events and status changes immediately.
• Address concerns professionally and directly, focusing on patient-centered decision-making.

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Communication with CRNAs when working in a care team

• If delegating to a CRNA, “the physician anesthesiologist must ensure that quality of care and patient safety are not compromised, participate in critical parts of the anesthetic, and remain immediately available for management of emergencies.” (4) Create a collaborative care plan that defines clear roles, duties, and scope of practice. The plan should also include clear protocols for case assignment and coverage.
• Define supervision requirements based on state regulations.
• Participate in regular pre-operative huddles for case planning.
• Establish protocols for escalation of concerns and maintain open communication for questions and clarification.
• Set up regular check-ins during long cases.
• Document the supervisory relationships for each case.
• Participate in regular feedback sessions with team members.
• Acknowledge and respect each other’s expertise and input.

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Communication with PACU staff

• Follow structured handoff protocols and include key information: patient status, medications, concerns, and plans.
• Provide clear instructions for patient care and ensure mutual understanding of postoperative orders.
• Acknowledge and respect nursing observations and concerns
• Foster a collaborative approach to patient monitoring

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Sources

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1. American Society of Anesthesiologists Standards and Practice Parameters Committee. Basic Standards for Preanesthesia Care. December 13, 2020. Available at https://www.asahq.org/standards-and-practice-parameters/basic-standards-for-preanesthesia-care . Accessed January 7, 2025.

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2. American Society of Anesthesiologists Standards and Practice Parameters Committee. Statement on Office-Based Anesthesia. October 23, 2024 (Original Approval: October 13, 1999). Available at https://www.asahq.org/standards-and-practice-parameters/statement-on-office-based-anesthesia#:~:text=Monitoring%20and%20Equipment,for%20scavenging%20waste%20anesthetic%20gases. Accessed January 17, 2025.

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3. Texas Administrative Code. Title 22. Examining Board. Part 9. Texas Medical Board. Chapter 173. Office-Based Anesthesia Services. Available at https://texas-sos.appianportalsgov.com/rules-and-meetings?chapter=173&interface=VIEW_TAC&part=9&title=22. Accessed January 17, 2025.

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4. American Society of Anesthesiologists Standards and Practice Parameters Committee. Statement on the Anesthesia Care Team. October 18, 2023 (original approval: October 26, 1982). Available at https://www.asahq.org/standards-and-practice-parameters/statement-on-the-anesthesia-care-team. Accessed January 17, 2025.



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