Table of Contents  
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 7-11

Anesthesia-related morbidity and mortality: where are we? A descriptive study

Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission13-Apr-2013
Date of Acceptance09-May-2013
Date of Web Publication31-May-2014

Correspondence Address:
Yasser A Salem
MD, 7, Bashar Ebn Bord st., Sixth district, Makram Ebied st. Nasr City, Cairo 11371
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1687-7934.128390

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Safe anesthesia practice is by default the ultimate target for every anesthesiologist. Mortality and morbidity discussions constitute the most important method to address this issue, although a well-designed productive mortality and morbidity discussion is rare. In this study we tried to initiate a project of a systematic mortality and morbidity analysis that could easily gather data about the incident. These data were statistically analyzable and could finally address the problem.
Materials and Methods
A total of 56 mortality and morbidity reports from July 2009 to August 2012 were reviewed. These were analyzed using a self-constructed chart. This chart was designed to achieve the goal of addressing the problem. This chart also assessed the degree of attribution of the incident to anesthesia, anticipation of the incidents, and the contributing factors that led to this incident.
Equal distribution of the three main categories of contributing factors (preoperative, intraoperative, and postoperative) was noticed, although 62% of the incidents could be easily gathered under a specific scenario of inappropriate preoperative management (20%) that led to improper choice of anesthesia (22%). Logically, this will lead to poor anticipation of intraoperative complications, followed by poor crisis management (14%) and finally insufficient postoperative management (6%). Hence, poor planning was responsible for 62% of the incidents. This result was supported by an almost similar percentage (65%) of unanticipated incidents. Moreover, 8% of the errors analyzed comprised system errors, which is a relatively high percentage.
Poor planning and nonanticipation of complications are the major problems that should be overcome by improving anesthesia planning. Also a stronger system is needed to minimize system errors.

Keywords: Anesthesia planning, anesthesia safety, morbidity and mortality, system error

How to cite this article:
Ewees B, Salem YA, Saleh M, Khairy MA. Anesthesia-related morbidity and mortality: where are we? A descriptive study. Ain-Shams J Anaesthesiol 2014;7:7-11

How to cite this URL:
Ewees B, Salem YA, Saleh M, Khairy MA. Anesthesia-related morbidity and mortality: where are we? A descriptive study. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2023 Sep 24];7:7-11. Available from:

  Introduction Top

Anesthesia is considered a risk by itself as it represents alteration of human physiology that may lead to morbidity and mortality. However, a number of investigators have reported a decline in anesthesia-related mortality over the last two decades.

Marx et al. [1] reported a mortality of eight per 10 000 cases in the USA in 1973. Bodlander [2] reported a mortality incidence of six per 10 000 in Australia in 1975. In 1978, Harrison [3] reported three cases per 10 000. In France in 1980, Tiret et al. [4] reported an incidence of three per 10 000 cases. The incidence has dropped in the first decade of the new millennium to around one per 10 000 cases [5].

Variation in these incidents was found to be mostly due to variance in the definition of perioperative mortality among these reports, in addition to variation in the quality of care in different countries. For example, Brazilian studies showed higher perioperative mortality rates, from 19 to 51 deaths per 10 000 anesthetics [5]. To date we have not found any report on anesthesia-related mortality in Egypt. That is why we could not compare our quality of practice with that of others.

It is not easy to define anesthesia-related problems, especially after expanding the period of time during which these problems could occur from during surgery in 1954 [6] to 1 year after the surgical procedure in some cases in 2005 [7].

In 1987, the Edwards classification was published to categorize the contribution of anesthesia to the incident. The incidents were classified into four categories according to the attribution of anesthesia to the incident [8].

Anticipation of medical problems during the surgical procedure is the first mission for the anesthesiologist. Anticipation of problems is very important for proper management and more effective handling. Classification for the extent of anticipation of the problem was designed to facilitate description of the situation. This classification was inspired from the ANZCA review of anesthesia-related mortality in Australia and New Zealand published in 2005 [9].

  Materials and Methods Top

Between July 2009 and August 2012, 56 morbidity and mortality reports were discussed by a Morbidity and Mortality Committee in the Anesthesia Department of Ain Shams University Faculty of Medicine. Confidentiality was ensured by not revealing the primary data in the reports examined.

These reports were analyzed using a self-constructed chart. This chart was designed to ensure uniformity in the report analysis. It concentrates on the degree of attribution of anesthesia to the incident, anticipation of the problem and factors contributing to the event, and its sequence. It aims to identify the most frequent reason responsible for problems.

To ensure ease in filling of the chart, a key explaining how to use it was designed and printed on the back of the chart. This included the Edwards classification and anticipation classification in addition to clear definitions for system, communication, and human errors.

Attribution (Edwards) classification

  1. Class I: the event was totally caused by anesthesia or by other factors totally under the control of the anesthetist.
  2. Class II: similar to class I but there is some doubt that other factors may be incriminated in the event.
  3. Class III: combined anesthetic and surgical factors led to the event.
  4. Class IV: the event was totally caused by surgical factors or by others under the control of the surgical team, or the event was inevitable irrespective of anesthesia or surgery, or the event was incidental and could not be reasonably expected during surgery or anesthesia.
  5. Class F: failure to reach a convincing scenario, although all needed data are available.
  6. Class S: shortage of data due to the situation of the case.

To avoid incoherence and lack of uniformity in description of types of error, a clear definition of human, communication, and system errors was adopted.

Human error: defect in cognitive, psychomotor, or affective aspects in individual management, further subdivided into provider characteristics, error in judgment, and mishaps.

Communication error: other individual defects specially related to inter-relations between individuals.

System error: defect related to administration.

  Results Top

Data collected from 56 mortality and morbidity reports were included in the mortality chart. These data were tabulated and analyzed.

Of the 56 reports, 38 (68%) were scheduled procedures.

Regarding the attribution of incidents to anesthesia, 20 of the 56 analyzed cases were totally attributed to anesthesia, with a percentage of 35% (class I). Combined attribution of anesthesia and surgical procedure was encountered in 39% of cases (class II and III). Only 25% of cases were not related to anesthesia practice (class IV).

Sixty-five percent of the incidents were not anticipated (class III and IV of anticipation classification), and 68% of the incidents were not managed properly (class II and IV).

An analysis of the frequency of factors that contribute to the occurrence of incidents revealed that intraoperative faulty anesthetic management was responsible for 59% of incidents; 20% related to preoperative management and another 16% related to postoperative management. All data are presented in the following table.

An analysis of the types of errors that contribute to the incidents revealed the following: 78% were human errors, 13% were communication errors, and 8% were system errors. These suggest a relatively high percentage of system errors, although this item was probably underestimated because of difficulty in system identification or lack of a solid system in some situations.

  Discussion Top

Anesthesia is considered a medical service provided to patients. Assessment of the quality of this service is mandatory for improvement. Moreover, evaluation of the contribution of anesthesia to perioperative mortality is mandatory in order to improve the safety and quality of care [10] [Figure 1].
Figure 1:

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We considered the quality assurance cycle and selected the point of monitoring the existing practice to enter the cycle.

Reporting and analyzing mortality related to anesthesia is important for identifying avoidable causes, for reviewing trends, and for formulating strategies for prevention. One of the major problems in reporting and comparing mortality incidents is lack of uniformity and solid definitions, especially in developing countries. Although we did not find any previous reports on Egyptian anesthesia practice, we had to maintain clear-cut standards while initiating this kind of report.

Hence, our main goal was to identify the most frequent problems behind perioperative morbidity and mortality in our practice, and we did not concentrate on the crude mortality rate. We tried to systematically analyze mortality and morbidity reports in a more objective way to direct our academic efforts toward the most common malpractices.

In an analysis presented by Harrison [11] on anesthesia-related mortality in Cape Town, South Africa, a six-fold decrease was reported over 30 years, from 1956 to 1987. It was believed that this change was due to intellectual response to information collected about these incidents.

The most frequent single contributing factor found was defective crisis management, which accounted for 13% of cases. Crisis management constitutes the most controllable area in anesthesia practice. This means that this relatively large portion of defective practice could be easily overcome by improved education and practice and by following the core algorithm (COVER-ABCD algorithm) and other subalgorithms [12]. The training course should be designed to educate anesthesia staff about when and how to use those algorithms.

Inadequate preoperative preparation and management accounted for 20% of the contributing factors in our report. Different studies from other developed countries reported a 40-45% contribution of preoperative management to incidents [13,14]. To our knowledge our number is underestimated because of lack of adequate registration and reporting, although a Pakistani study has reported a figure of only 12%; this Pakistani study was performed in Aga Khan University Hospital, which is one of the most renowned institutes in medical service in Pakistan [15]. This wide variation in number is mostly due to lack of uniformity in definition and in data analysis in addition to defects in data collection and reporting in such countries.

In our study 68% of cases were not managed properly, indicating that the remaining 32% of incidents were inevitable. This rate is relatively low in comparison with that of other developing countries. Khan and Khan [15] reported 43% inevitable deaths in which anesthesia and surgical techniques were apparently satisfactory. Our relatively high rate could be explained by the fact that we included all mortality and morbidity incidents in our report in contrast to the inclusion of only deaths in their report.

In contrast, 65% of cases were not anticipated, which is considered a relatively high rate. If we accept the following algorithm for analyzing the ability to anticipate adverse outcome we could simply identify problems behind this anticipation defect [Figure 2].
Figure 2:

Click here to view

Communication errors are characterized by being easily avoidable. In our report it comprises 13% of factors contributing to incidents. This reflects the need for better learning and practice of communication skills. If we combined this result with a 20% defect in preoperative management as discussed before, keeping in mind that 68% of our cases were scheduled cases, we can conclude that there is a dearth of case discussion of elective procedures or that we need to improve our preoperative communication skills (either interanesthetist or anesthetist-surgeon).

The relatively high percentage of system-related defects (8%), which is usually negligible in other audits, may reflect the need for tighter systems to control our anesthesia practice. Ironically, we believe that this rate is underestimated because of the difficulty we faced in identifying the system itself while diagnosing system errors. Nevertheless, audits from other developing countries are in agreement with ours in the suggestion that the overall contribution of the human factor may be much smaller than often cited and the contribution of system-related factors is higher [16].

  Conclusion Top

Our first attempt at reviewing our anesthesia practice concluded that we need clearer and tighter systems. Our communication skills need to be improved. Our preoperative assessment and management need to be more effective for better planning of anesthetic procedures. Moreover, we should direct more attention toward learning more about crisis management. Finally, this work is the first step to running our own cycle of service improvement.

  Acknowledgements Top

Conflicts of interest

None declared.

  References Top

1.Marx GF, Mateo CV, Orkin LR. Computer analysis of postanesthetic deaths. Anesthesiology 1973; 39:54-58.  Back to cited text no. 1
2.Bodlander FM. Deaths associated with anesthesia. Br J Anaesth 1975; 47:36-40.  Back to cited text no. 2
3.Harrison GG. Death attributable to anaesthesia: a 10-year survey (1967-1976). Br J Anaesth 1978; 50:1041-1046.  Back to cited text no. 3
4.Tiret L, Desmonts JM, Hatton F, Vourc′h G. Complications associated with anaesthesia - a prospective survey in France. Can Anaesth Soc J 1986; 33:336-344.  Back to cited text no. 4
5.Braz LG I, Braz DG II, Cruz DS I, Fernandes LA I, Módolo NS I, Braz JR I. Mortality in anesthesia: a systematic review. Clinics 2009; 64:999-1006.  Back to cited text no. 5
6.Beecher HK, Todd DP. A study of deaths associated with anesthesia and surgery: based on a study of 559 548 anesthesias in ten institutions 1948-1952, inclusive. Ann Surg 1954; 140:2-35.  Back to cited text no. 6
7.Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg 2005; 100:4-10.  Back to cited text no. 7
8.Holland R. Anaesthetic mortality in New South Wales. Br J Anaesth 1987; 59:834-841.  Back to cited text no. 8
9.Gibbs N. Safety of anaesthesia: a review of anaesthesia-related mortality reporting in Australia and New Zealand 2003-2005. ANZCA College Publications; 2005. Available at: [Last accessed on 2013 April 04].  Back to cited text no. 9
10.Mellin-Olsen J, O′Sullivan E, Balogh D, Drobnik L, Knape JTA, Petrini F, Vimlati L. Guidelines for safety and quality in anaesthesia practice in the European Union. Eur J Anaesthesiol 2007; 24:479-482.  Back to cited text no. 10
11.Harrison GG. Death due to anaesthesia at Groote Schuur Hospital, Cape Town 1956-87. Part II. Causes and changes in aetiological pattern of anaesthetic-contributory death. S Afr Med J 1990; 77:416-421.  Back to cited text no. 11
12.Runciman WB, Kluger MT, Morris RW, Paix AD, Watterson LM, Webb RK. Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. Qual Saf Health Care 2005; 14:156-163.  Back to cited text no. 12
13.Warden JC, Borton CL, Horan BF. Mortality associated with anaesthesia in NSW 1984-1990. Med J Aust 1994; 161:585-593.  Back to cited text no. 13
14.Arbous MS, Grobbee DE, Van Kleef JW, de Lange JJ, SPOORMANS HH, TOUW P, et al. Mortality associated with anaesthesia: a qualitative analysis to identify risk factors. Anaesthesia 2001; 56:1141-1153.  Back to cited text no. 14
15.Khan M, Khan FA. Anesthetic deaths in a developing country. Middle East J Anesthesiol 2007; 19:159-172.  Back to cited text no. 15
16.Runciman WB, Webb RK, LEE R, Holland R. The Australian Incident Monitoring Study. System failure: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:684-695.  Back to cited text no. 16


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