• Joachim Koppenberg, Dietrich Stoevesandt, Stefan Watzke, David Schwappach, and Michael Bucher.
• Department of Anaesthesiology, Pain Therapy and Emergency Medicine, Lower Engadine Hospital and Health Centre, Scuol, Switzerland (JK), Dorothea Erxleben Lernzentrum Halle, Medical Faculty of Martin Luther University of Halle-Wittenberg, Halle, Germany (DS), Department of Psychiatry, Psychotherapy, and Psychosomatics, University Hospital of Halle (Saale), Germany (SW), Stiftung Patientensicherheit Schweiz, Zurich, Switzerland (DS), Institute for Social and Preventive Medicine (ISPM), University of Bern, Switzerland (DS) and Department of Anaesthesiology and Surgical Intensive Care Medicine, University Hospital of Halle (Saale), Germany (MB).
• Eur J Anaesthesiol. 2022 Jan 1; 39 (1): 334133-41.

BackgroundAnaesthesiology is one of the safest fields in medicine today in relation to mortality. Deaths directly because of anaesthesia have fortunately now become rare exceptions. Nevertheless, important findings can still be drawn from the rare deaths that still occur.ObjectiveThe aim of this study was to identify and analyse the causes of deaths related to anaesthesia alone over a 10-year period.DesignRetrospective structured analysis of a database of medical liability claims.SettingHospitals at all levels of care in Germany.PatientsThe database of a large insurance broker included data for 81 413 completed liability claims over the 10-year period from 2006 to 2015. Among 1914 cases associated with anaesthetic procedures, 56 deaths were identified. Of these, 30 clearly involved anaesthesia (Edwards category 1) and were included in the evaluation.InterventionsNone (retrospective database analysis).Main Outcome MeasuresCauses of anaesthesia-related death identified from medical records, court records, expert opinions and autopsy reports.ResultsThe 30 deaths were analysed in detail at the case and document level. They included high proportions of 'potentially avoidable' deaths, at 86.6%, and what are termed 'never events', at 66.7%. Problems with the airway were the cause in 40% and problems with correct monitoring in 20%. In addition, communication problems were identified as a 'human factor' in 50% of the cases.ConclusionThe majority of the anaesthesia-related deaths investigated could very probably have been avoided with simple anaesthesiological measures if routine guidelines had been followed and current standards observed. Actions to be taken are inferred from these results, and recommendations are made. In future, greater care must be taken to ensure that the level of safety already achieved in anaesthesiology can be maintained despite demographic developments and increasing economic pressures.Copyright © 2021 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.

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