Page 10 of 11
AS10.1-4 | Patient Safety in Anaesthesiology — Assignment
CLINICAL SCENARIO
Students will analyse a realistic perioperative adverse event narrative and produce a structured safety audit report — the kind of document that would be submitted to a hospital quality committee or departmental morbidity and mortality (M&M) meeting. The report must identify all positioning hazards and perioperative hazards in the scenario, classify communication failures and medication errors using recognised frameworks, and propose concrete, implementable prevention strategies. This is a clinical deliverable: it requires not just knowing what went wrong, but formulating actionable system-level recommendations that a department could actually adopt.
Instructions
- Read the scenario below carefully. You are the anaesthetic registrar conducting the post-event review.
Scenario: A 68-year-old male patient (body weight 92 kg, BMI 33 kg/m2) was scheduled for a 5-hour laparoscopic anterior resection. He was positioned in the modified lithotomy position with steep Trendelenburg tilt. Intraoperatively, the patient developed progressive desaturation (SpO2 falling from 99% to 87%) that the anaesthetist initially attributed to the long case without systematic review. A syringe labelled metaraminol 1 mg/mL was found unlabelled on the drug tray at case end; the scrub nurse noted that two clear unlabelled syringes had been present side by side during the vasopressor administration period. At handover to recovery, the anaesthetist verbally said he was a bit desaturated but he is fine now before leaving. Postoperatively, the patient had bilateral calf pain and the left leg showed signs of compartment syndrome; he also reported his right hand felt numb along the little and ring fingers.
- Identify and classify ALL positioning hazards present in this case (minimum 3). For each, name the specific hazard, the affected structure or system, and cite the mechanism of injury.
- Identify the perioperative non-positioning hazards. For each, describe the physiological mechanism and what a systematic review would have detected at the time.
- Classify each communication failure using a recognised framework (e.g., Reason taxonomy, SBAR deficiency, hierarchy-induced silence, broken closed-loop). Explain why each classification applies.
- Identify and classify each medication error using the IOM/Reason taxonomy (slip, lapse, mistake, violation; active vs latent failure). For the unlabelled syringe: state what drug and concentration was likely being administered and why the labelling failure is a latent system error, not just an individual fault.
- For each hazard and error identified, propose ONE specific, implementable prevention strategy. Strategies must be actionable (not generic statements like be more careful). Include at least one system-level intervention.
- Draft a single summary recommendation suitable for presentation to a departmental M&M meeting (150-200 words), identifying the highest-priority change the department should implement.
Length: 700-1000 words (excluding the scenario text). Tabular format for hazard classification is acceptable and encouraged — it demonstrates structured clinical thinking.
Grading Rubric — Patient Safety in Anaesthesiology Assignment Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Hazard identification and classification: accuracy and completeness of positioning and perioperative hazards identified (minimum 3 positioning + 2 perioperative), with correct mechanism for each | 30 pts | All 5+ hazards correctly identified with accurate anatomical and physiological mechanism for each; no factual errors in nerve anatomy, compartment syndrome mechanism, or respiratory physiology |
| Error classification: correct application of communication failure and medication error taxonomy (Reason/IOM frameworks) with justification for each classification | 25 pts | All communication failures correctly classified (SBAR deficiency + broken closed-loop at minimum); unlabelled syringe correctly identified as latent system error with active failure layer; classifications are justified with specific evidence from the scenario |
| Prevention strategies: specificity, implementability, and three-level coverage (individual/team/system); at least one system-level intervention | 25 pts | Each hazard/error matched with a specific, named, implementable intervention; at least one system-level engineering or design change (e.g., mandatory syringe labelling policy with audit, automatic allergy alert, WHO checklist lithotomy time limit); strategies are concrete and actionable |
| M&M summary recommendation: clarity, prioritisation, departmental actionability, and professional register (suitable for quality committee) | 20 pts | 150-200 word summary written in professional clinical register; clearly identifies the single highest-priority change with rationale; recommendation is specific enough to be actioned by a department without further clarification |
PEER REVIEW
Review your peer submission against these criteria: (1) Check that at least 3 positioning hazards are named with the correct nerve/structure and mechanism — flag any where the anatomy is incorrect. (2) Verify that the compartment syndrome mechanism is described as a two-hit injury (not just position caused it). (3) Evaluate whether the unlabelled syringe is classified as a latent system error or merely an individual fault — which is more accurate and why? (4) Are the prevention strategies genuinely actionable, or are they generic statements? Name the weakest strategy and suggest a more specific replacement. (5) Would the M&M recommendation be sufficient for a quality committee to initiate a change? If not, what specific information is missing?