Departments should have a clear process to consider national guidance from recognised bodies. This should include a review of the guidance and a decision on whether these require local implementation and endorsement.
All guidelines should have a clearly documented author and review date and should be published in line with local clinical governance policies with appropriate oversight.
Relevant patient information should be recorded and kept up to date.
All anaesthetic records should contain the relevant portion of the recommended anaesthetic data set for every anaesthetic and should be kept as a permanent document in the patient’s medical record.
The use of electronic anaesthetic records in the perioperative period should be considered.79 Departments that currently do not have access to electronic anaesthetic records should link with wider hospital plans for the development of electronic patient records.
If electronic health records are in use there should be a clearly labelled anaesthetic record section so that documentation can be easily accessed.
Departments should have a culture of capturing learning and sharing it within and beyond the department to support further improvement in the future, building a robust system to ensure that learning is embedded in clinical practice.
The culture should proactively promote safety, by emphasising what goes right rather than what went wrong (Safety 1 and Safety 2, see Glossary).80The emphasis of the anaesthetic department should be on incident prevention rather than solely focusing on making changes after an incident has occurred.77
The department should have a system for reporting, investigating, sharing learning and regular audit of critical incidents.43,83,84,85The methodology should be explicit and should identify underlying relevant factors to inform learning and development of safe systems, as well as enabling thematic analysis, continuous monitoring and evaluation.77
