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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

Learning from negative episodes should be promoted within an ethos of support and avoidance of blame. This approach should be embedded throughout the department and the organisation as a whole.^81,82

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

The department should have a process to disseminate learning from incidents widely, both within the department and elsewhere in the organisation where appropriate.

Within the process for dealing with critical incidents, positive feedback should be emphasised and changes made to avoid recurrence.