Get the basics done and documented: Good practice for anaesthetic practitioners in the operating room to safeguard the patient’s intraoperative journey

10 Oct 2025 Estimated read time: 6 min read

Case study highlighting practical anaesthetic safety measures, focused on preparation, medication handling, and documentation to reduce risk and support medicolegal defence.

Hospital corridor with two people in scrubs

Dr Danny KY Ip, currently Director of Perioperative Care at Gleneagles Hospital (Hong Kong), is a specialist in anaesthesiology with interests in vascular anaesthesia and perioperative medicine. He has extensive administrative experience, particularly in the area of medication safety, from his work as a Consultant Anaesthesiologist in the Hospital Authority. In this article, he shares practical insights into anaesthesia-related operating room practices which are not only fundamental to improving patient safety but also serve as vital protection for medical practitioners in the event of medicolegal enquiries.

Pre-anaesthetic preparation and the checklist

“Hours of boredom, moments of horror” is a phrase often recited during anaesthetic training. Although most patients pass through anaesthesia uneventfully, crisis can develop suddenly and without forewarning. The key lesson is preparedness: anaesthesiologists must never underestimate the importance of thorough preparation, even on ‘routine days’. Developing strong habits in performing systematic pre-induction theatre checks provides the bedrock of safe practice. These habits should never diminish under time pressure or the assumption of autonomy at senior levels.

Before the start of surgery, anaesthesiologists must inspect and confirm that all monitoring equipment, airway devices, and specialist instruments are present, functional, and appropriate for the case. The professional body — the College of Anaesthesiologists — recommends a full ventilator check before the day’s first case and whenever ventilator equipment is altered. Reliance solely on non-medical staff assurances or indirect reports about equipment readiness is insufficient. Importantly, these checks, along with the completion time and findings, should be explicitly documented in the anaesthetic record, thereby serving both patient safety and medicolegal accountability.

Medication preparation and safety

Unlike most medical specialties, anaesthesiologists uniquely shoulder the full responsibility of prescribing, preparing, and administering drugs. The conventional “three-check and five-right” safety framework commonly applied by nursing staff is, therefore, absent. Consequently, the entire liability for medication safety falls upon the anaesthesiologist. This is especially critical given that many anaesthetic drugs exert profound and potentially life-threatening effects – either suppressing respiration (e.g., opioids, muscle relaxants) or causing haemodynamic instability (e.g., vasopressors).

Preparation requires more than simply selecting appropriate drugs. Many intravenous anaesthetic medications are delivered in concentrated form, requiring precise dilution. Errors in dilution or labelling can lead to catastrophic consequences. The fact that most anaesthetic drugs are colourless, while their ampoules may appear similar, significantly compounds the risk of error. Institutions should, therefore, standardise dilution protocols. A unified guideline ensures consistency across practitioners and reduces variability during handovers.

Equally vital is drug labelling. International standards recommend pre-printed, colour-coded labels (e.g., yellow for induction agents, blue for opioids, red for muscle relaxants) and robust institutional policies should ensure their availability. Handwritten ad hoc labels increase the risk of misidentification. Indeed, documented adverse events have occurred in which mislabelled syringes containing phenylephrine were mistaken for saline flushes, or where improper dilutions of remifentanil resulted in dangerously high inadvertent boluses. These cases exemplify how lapses in vigilance are difficult to defend in court, irrespective of intent.

Commercially prepared prefilled or prediluted syringes — particularly for high-risk drugs such as adrenaline, phenylephrine, and naloxone — are an effective mitigation strategy. Though their cost is higher than self-prepared alternatives, they reduce preparation errors and enhance readiness during emergencies when prompt administration is necessary. From a systems perspective, the higher upfront investment may be justified by avoiding catastrophic harm and the downstream medicolegal repercussions associated with medication errors.

Moreover, segregation of prepared syringes into clear, standardised containers (opioids in blue, local anaesthetics in yellow, etc.) is essential. Drugs left unfinished should be discarded rather than randomly dispersed on the trolley, as confusion between half-used syringes often precipitates error. Medication vigilance must be regularly reinforced at departmental level; when medication errors cause patient harm, they are among the most difficult to defend legally.

The WHO surgical safety checklist

The World Health Organisation’s (WHO) Surgical Safety Checklist has become a global standard to enhance operating room safety. Prior to anaesthesia, this “sign-in” process verifies critical details: patient identity, procedure, laterality, allergies, and perioperative risks. Importantly, this provides patients with a final opportunity to clarify uncertainties directly with their surgeon and anaesthesiologist.

In addition, institutions should implement tailored “time-out” procedures for invasive procedures, such as regional blocks and vascular access. These should be standardised, documented, and endorsed by both the anaesthesiologist and theatre nurse. The recent Association of Anaesthetists’ guidelines on vascular access offer an invaluable template, including a checklist for central venous catheter insertion. Adoption and adaptation of such frameworks strengthen institutional standards while safeguarding practitioners.

Intraoperative documentation

Electronic anaesthesia records increasingly automate physiological monitoring data capture, which improves accuracy and reduces clerical burden. Yet, manual documentation of background case details, medication administration, and critical events remains indispensable. The purpose of the anaesthetic record is not only internal continuity but also to create a contemporaneous, medicolegal proof of what transpired in the operating theatre. Retrospective supplementation is often incomplete and, in some circumstances, inappropriate.

Clinicians should document in real time, especially during critical milestones such as airway management. Records should reflect the timing, number of intubation attempts, airway device employed, adequacy of ventilation, and oxygenation throughout attempts. Similarly, extubation should include whether the patient was awake, breathing spontaneously, and haemodynamically stable prior to tube removal. Medication entries must follow chronological logic, aligning and matching induction doses with subsequent stages of the procedure.

Furthermore, non-anaesthetic perioperative events – such as communication regarding massive haemorrhage or a surgical decision to stage an operation due to instability — should also be recorded. These often prove vital during multidisciplinary incident reviews.

To ensure compliance, departments should institute regular record audits and educate trainees about the medico-legal importance of appropriately detailed records. Simply put, if an action is not documented, it is difficult to prove that it occurred.

Handover and post-anaesthesia care

Anaesthetic management does not conclude at theatre exit. Immediate post-anaesthetic complications, including respiratory depression due to residual drugs or haemodynamic compromise, remain risks, particularly among frail patients with multiple comorbidities. Effective communication during handover to post-anaesthesia care unit (PACU) nurses is therefore essential. Apart from case summaries, anaesthesiologists should provide focused instructions, including specific thresholds at which nursing staff should escalate care – for example, blood pressure targets or thresholds of concern in high-risk patients.

Many institutions utilise formal discharge protocols from PACU, such as the Modified Aldrete Score. While such nurse-led protocols enable efficiency, they do not absolve the anaesthesiologist of overall responsibility for postoperative patient safety. Practitioners must remain available, review selected cases in person where appropriate, and clearly document post-anaesthesia reviews when conducted.

Take-home message

The safe perioperative journey hinges on good habits, consistent attention to detail, and clear documentation. By upholding these practices, anaesthesiologists not only improve patient outcomes but also safeguard themselves in the event of scrutiny. As in much of anaesthetic practice, diligence in the routine – getting the basics done and documented – forms the best defence against both clinical harm and medicolegal vulnerability.