EDAIC Ethics, Patient Safety, and Quality in Anaesthesia Practice — Questions and Answers
Question 1: For informed consent to anaesthesia to be legally and ethically valid, which of the following is the most complete description of what the patient must be told?
- Only complications occurring in more than 1% of cases
- The nature, purpose, material risks, benefits, and reasonable alternatives of the proposed anaesthetic (Correct answer)
- The statistical probability of each complication from published meta-analyses
- Only the most serious (potentially fatal) complications
Correct answer: The nature, purpose, material risks, benefits, and reasonable alternatives of the proposed anaesthetic
Valid informed consent requires disclosure of the nature of the procedure, its purpose, the material risks (those a reasonable patient would want to know, even if rare), the benefits, and available alternatives including no treatment. The 'material risk' standard (established in Montgomery v Lanarkshire and equivalent European case law) replaced the old 'reasonable doctor' standard — the patient's perspective now determines what must be disclosed, not just what clinicians deem important.
Question 2: James Reason's 'Swiss cheese model' of accident causation is widely applied in patient safety. What does it describe?
- The tendency for Swiss healthcare institutions to have superior safety cultures
- Multiple defensive system layers each containing latent failures; harm occurs when failures in all layers align simultaneously (Correct answer)
- A root cause analysis method in which errors are attributed to individual negligence
- A grading system for anaesthetic adverse events based on severity
Correct answer: Multiple defensive system layers each containing latent failures; harm occurs when failures in all layers align simultaneously
In Reason's model, healthcare systems have multiple defensive barriers (like slices of cheese), each with latent holes (system weaknesses, not just individual errors). A critical incident occurs when holes in successive layers momentarily align, allowing a hazard to pass through all defences and cause harm. This model shifted safety thinking from 'blame the individual' to 'fix the system'.
Question 3: The WHO Surgical Safety Checklist is structured around three pause points during the surgical episode. Which of the following correctly identifies all three?
- Pre-admission, pre-induction, post-operative
- Sign In (before induction), Time Out (before skin incision), Sign Out (before patient leaves theatre) (Correct answer)
- Pre-operative ward round, anaesthetic room check, recovery room handover
- Consent, anaesthetic machine check, post-operative review
Correct answer: Sign In (before induction), Time Out (before skin incision), Sign Out (before patient leaves theatre)
The WHO Surgical Safety Checklist (introduced 2008) comprises: (1) Sign In — before induction of anaesthesia, confirming patient identity, consent, allergies, airway assessment, and anaesthetic machine check; (2) Time Out — before skin incision, confirming team introductions, procedure, site, imaging, and antibiotic prophylaxis; (3) Sign Out — before the patient leaves theatre, confirming instrument/swab counts, specimen labelling, and recovery plan. Systematic use has been shown to reduce surgical mortality and complication rates.
Question 4: A competent adult Jehovah's Witness patient has signed an advance refusal of blood products and verbally reaffirms this refusal in the anaesthetic room before emergency laparotomy for a ruptured ectopic pregnancy. The surgeon believes transfusion will be necessary to prevent death. What is the ethically and legally correct action?
- Transfuse immediately — preservation of life overrides refusal in an emergency
- Obtain an emergency court order permitting transfusion
- Respect the patient's refusal and proceed without blood products, using all available blood conservation strategies (Correct answer)
- Delay surgery until a psychiatrist certifies the patient lacks capacity
Correct answer: Respect the patient's refusal and proceed without blood products, using all available blood conservation strategies
A competent adult's advance refusal of treatment — when made with full understanding of the consequences — is legally binding and must be respected even if it results in the patient's death. Overriding the refusal would constitute unlawful battery. The duty of the anaesthetist is to respect autonomy while employing maximum blood conservation techniques (cell salvage, haemostatic agents, permissive hypotension). The ethical framework here is respect for patient autonomy, which outweighs paternalistic beneficence.
Question 5: Critical incident reporting systems in anaesthesia departments encourage reporting of 'near miss' events. What is the primary rationale for analysing near misses rather than focusing only on adverse outcomes?
- Near misses require mandatory financial compensation to the patient
- Near misses expose system vulnerabilities before harm reaches the patient, enabling preventive system changes (Correct answer)
- Near misses are legally equivalent to adverse events in all European jurisdictions
- Near misses occur less frequently than actual adverse events and are therefore more informative
Correct answer: Near misses expose system vulnerabilities before harm reaches the patient, enabling preventive system changes
Near misses ('close calls') are incidents where a harmful outcome was averted by chance or last-minute intervention. They are far more frequent than serious adverse events and share the same upstream causal factors. Analysing them identifies latent system failures before harm occurs — providing a low-cost, high-yield opportunity for system improvement. This is central to High Reliability Organisation (HRO) principles in healthcare.
Question 6: The 'duty of candour' in anaesthetic practice requires a clinician to do which of the following when an intraoperative complication affects a patient?
- Report the incident to the police within 24 hours
- Proactively inform the patient (or their representative) that something went wrong, apologise, and explain what is known and what will be done (Correct answer)
- Only disclose the complication if the patient asks specifically about it
- Maintain confidentiality about the complication to protect other team members from blame
Correct answer: Proactively inform the patient (or their representative) that something went wrong, apologise, and explain what is known and what will be done
Duty of candour — now enshrined in professional codes across Europe (GMC, professional societies) and statute in some jurisdictions — requires healthcare professionals to be open and honest with patients when things go wrong. This includes: telling the patient something has gone wrong, offering an apology, explaining what happened and its short-term effects, and outlining the steps being taken to minimise harm and prevent recurrence. Candour applies proactively, not only in response to patient enquiry.
EDAIC Ethics, Patient Safety, and Quality in Anaesthesia Practice
For informed consent to anaesthesia to be legally and ethically valid, which of the following is the most complete description of what the patient must be told?