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Rate of undesirable events at beginning of academic year: retrospective cohort study

BMJ 2009; 339 doi: (Published 14 October 2009) Cite this as: BMJ 2009;339:b3974

Increase in the rate of undesirable events at the beginning of the academic year: a universal problem

We are grateful our article triggered such an interesting debate. A
number of respondents questioned the generaliseability of our findings and
the presence of a higher rate of undesirable events at the beginning of
the academic year beyond the field of anaesthesia.We truly believe it
might be even higher elsewhere.

Anaesthesia is one of the specialties that has made the most
significant strides in improving patient safety and is often cited as a
model. Whereas the overall adverse events related death toll rates in
Australian, Canadian, UK, US and New Zealand hospitals are estimated to be
between 5.1 and 12 in 1000 cases,[1] anaesthesia itself is considered to
be responsible for 0.6 to 7.7 in 100 000 adverse events related death
cases.[2,3] The administration of anaesthesia is highly standardised and
regular safety checks and drills are part of standard procedures. The
level of supervision of first year anaesthesia residents/registrars is
very high. A one to one supervision level is usually the rule, including
in our study setting.

Because the delivery of anaesthesia occurs in a complex and dynamic
environment, many events can occur over a short period of time. Quality
assurance programmes for anaesthesia require these events to be
systematically recorded. As a consequence, many events are captured during
anaesthesia care, which go unnoticed in other specialty care-“one can only
see what one is measuring”. To cite P Barach & J Johnson’s excellent
editorial [4], it is time to see “the elephants in the room”.

We can no longer introduce young trainees in incredibly complex and
sometimes chaotic working environments without a minimal level of
preparation. We can no longer expect high performance from trainees who
change hospital and departments every 3 or 6 months for “training
purposes”. We can no longer expect someone completely unfamiliar with a
healthcare organisation’s setting, other staff members and working
practices to learn everything “as by magic” on the first day. Professional
expertise relies not only on medical knowledge and skills but also on
adequate knowledge of the specificities of the working environment and
awareness of teamwork related factors. It is time to understand that
medical training does not take place within a speciality and professional
silo but in the wider context of a healthcare organisation (hospital,
clinics, practice …).
It is not anaesthesia’s problem. It is everyone’s problem


1.De Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA.
The incidence and nature of in-hospital adverse events: a systematic
review. Qual Saf Health Care. 2008;17(3):216-23

2. Mackay P, Cousins M . Safety in anaesthesia .Anaesth Intensive
Care. 2006 ;34(3):303-4.

3. Lagasse RS. Anesthesia safety: model or myth? A review of the
published literature and analysis of current original data.
Anesthesiology. 2002;97(6):1609-17

4. Barach P, Johnson JK. Reducing variation in adverse events during
the academic year. BMJ. 2009 Oct 13;339:b3949

Competing interests: First author – no competing interest declared

Competing interests:
None declared

Competing interests: No competing interests

09 November 2009
Guy Haller
1211 Geneva Switzerland
Department of Anaesthesia, Pharmacology and Intensive Care Geneva University Hospital