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Safety & Ethics

Sheet 10Anaesthesia

Safety & Ethics

Consent with and without capacity, disclosure and incident reporting, DNR orders and brain death, research ethics and statistics, the WHO checklist and infection control.

Cards
24
Minutes
about12
Scenarios
23

Start at card 1Review the rules

Core rulesRead these first3 cards · about 1 min

  1. 01Valid consent
  2. 02Truth and disclosure
  3. 03Reporting incidents

Valid consent

01 / 24

Valid consent needs a capable patient, told the alternatives, agreeing freely by word or gesture.

Principles of valid consent

Principle or elementWhat it means
Autonomy, open its explanationAdult with capacity decides, may refuse lifesaving treatment
Disclosure of reasonable alternatives, open its explanationRequired, e.g. general for spinal; else signature invalid

Misleading bedside findings

FindingWhat it really shows
Dysarthria, deafness or aphasia, open its explanationMimic incapacity; dementia, immaturity, anxiety, pain can impair
Nodding or baring arm for cuff, open its explanationValid consent; need not be written or spoken

Report a problem with card 1: Valid consent

Truth and disclosure

02 / 24

Tell the truth: disclose every error and never deceive a patient, even at a guardian's request.

Principle

PrincipleWhat it means
Veracity, open its explanationTruthfulness: tell the truth, including errors, tactfully, at their level

Errors and requests to deceive

After an error or a request to deceiveWhat to do
Error or complication, harmful or not, open its explanationDisclose fully to patient or family, senior leading; never conceal
Guardian asks to lie to teenager about surgery, open its explanationGuardian consents; explain real operation, seek assent, persuade guardian

Report a problem with card 2: Truth and disclosure

Reporting incidents

03 / 24

Report every incident, harmful or not, patient or visitor; analyse systems, not people; silence means under-reporting.

Incident

IncidentHow it is reported
Visitor fall or injury in hospital, open its explanationTreat injury; file incident report in safety‑reporting system
Wrong‑drug error causing serious harm, open its explanationSentinel event; report to risk management, triggers root cause analysis

Reporting pattern

Reporting patternWhat it suggests
Long stretch with zero reported medication errors, open its explanationLikely under‑reporting, not proof of safe practice

After the report

After the reportWhat it is for
Root cause analysis, open its explanationStructured systems review of why event happened; prevents recurrence

Report a problem with card 3: Reporting incidents

Part 1 · DecisionsWhat to do10 cards · about 4 min

  1. 04The capable adult's consent
  2. 05Consent without capacity
  3. 06Demands and requests
  4. 07Team communication
  5. 08Do-not-resuscitate (DNR) orders and the end of life
  6. 09Brain death and organ donation
  7. 10Called to court
  8. 11Safety and quality programmes
  9. 12Drug company offers
  10. 13Research ethics

The capable adult's consent

04 / 24

A capable adult decides: accept his refusal; postpone and explain when he has not understood.

Conscious adultWhat to do
Capable adult refuses anaesthesia, even lifesaving, open its explanationAccept refusal: do not proceed or coerce
Blind but understands and communicates, open its explanationCapable; a relative's consent does not replace his
Vague 'do what you think best', elective surgery, open its explanationNot consent: postpone, address fear or confusion, re‑consent when understood

Report a problem with card 4: The capable adult's consent

Consent without capacity

05 / 24

Patient unable to decide: elective waits; a minor's guardian in order; an emergency needs two specialists.

Patient unable to consent nowWho authorises, or when
Elective procedure changes after sedative premedication, open its explanationWait until sedative wears off, then retake consent
Under 15, father unavailable, open its explanationNext in order: paternal grandfather, then mother; not child
Delay threatens life or organ, no guardian now, open its explanationTwo specialists confirm, document necessity; operate without consent
Non‑urgent, no guardian able to consent, open its explanationFacility committee consents

Report a problem with card 5: Consent without capacity

Demands and requests

06 / 24

Clinical need and the law decide, not fame, insurance, your shift or the request itself.

Demand on your careWhat to do
Celebrity arriving during urgent work, open its explanationFinish the urgent task; he waits his turn
Emergency arriving after shift, relief absent, open its explanationSee and stabilise until a qualified doctor takes over
Request for every test, insured or consented, open its explanationOrder only indicated tests; explain this to the patient
Request for abortion, open its explanationTake history; mother's life, or committee‑confirmed risk before four months

Report a problem with card 6: Demands and requests

Team communication

07 / 24

Structure team communication: daily goals at rounds, face-to-face handover, one leader who listens.

Team needWhat works
ICU teamwork and daily coordination, open its explanationStructured sheet of daily goals used during bedside rounds
ICU shift handover, open its explanationFace to face, fixed interruption‑free time and place, structured protocol
Cardiac arrest team organisation, open its explanationOne leader who listens to all; not multiple or none

Report a problem with card 7: Team communication

Do-not-resuscitate (DNR) orders and the end of life

08 / 24

A DNR is signed by rule and reviewed deliberately, never dropped automatically; death is never hastened.

Patient near the end of life

Patient near the end of lifeWhat to do
Emergency surgery with a signed DNR, open its explanationOperate if it serves goals; DNR stays until reviewed
Family or surgeon wants the DNR dropped, open its explanationNot dropped on request; review, then keep, limit or suspend
DNR order going to theatre, open its explanationRevisit, agree accepted interventions, document; never auto‑suspend
Request to hasten death in terminal illness, open its explanationRefuse; treat suffering with strong analgesia

The DNR order itself

The DNR order itselfWho signs
Saudi DNR: CPR judged futile, open its explanationThree qualified physicians, including a minimum of one consultant; no family consent

Report a problem with card 8: Do-not-resuscitate (DNR) orders and the end of life

Brain death and organ donation

09 / 24

Once brain death is declared, notify the organ procurement organisation; donation consent comes from the family.

After brain deathNext step or who consents
Brain death declared, open its explanationNotify organ procurement organisation; keep supporting organs
Repeat examinations and confirmatory tests, open its explanationComplete before brain death is declared
Organ donation consent, open its explanationDeceased's family as a whole; no relative ranked

Report a problem with card 9: Brain death and organ donation

Safety and quality programmes

11 / 24

Fit the fix to the need: assess hazards first, then choose the intervention or tool.

NeedApproach
Many hospital hazards, no fixes chosen yet, open its explanationRisk assessment: rank by likelihood and severity
Hospital‑wide hand hygiene and aseptic technique, open its explanationQuality‑improvement programme: targets, combined interventions, audit, feedback; not teaching alone
Rifampicin's orange urine, an expected alarming effect, open its explanationWarn face to face; say not to stop
Clinician feedback on quality or documentation measures, open its explanationDashboard, whether live or periodically updated

Report a problem with card 11: Safety and quality programmes

Drug company offers

12 / 24

A company's offer never decides: refuse personal payments and gifts; judge its drugs on evidence.

Company offerResponse
Personal payment from a drug company, open its explanationRefuse, even a speaker's fee
Educational grant from a drug company, open its explanationOnly your employing institution may accept it
Trip, gift or reward for recommending or prescribing, open its explanationConflict of interest: decline it
Company‑promoted drug, open its explanationAppraise against current evidence and alternatives first

Report a problem with card 12: Drug company offers

Part 2 · RecognitionWhat it is4 cards · about 2 min

  1. 14Errors and incidents by type
  2. 15Study design and its measures
  3. 16Describing data
  4. 17Tests and P values

Errors and incidents by type

14 / 24

Classify each event by its cause and whether harm reached the patient, not by who erred.

Term

TermDefinition
Medical error, open its explanationPlanned action not completed as intended, or wrong plan

Classifying an event

EventClassification
Dangerous error stopped before reaching the bedside, open its explanationNear miss; reached without injury: no‑harm event
Known complication needing treatment, despite full recovery, open its explanationHarmful incident
Staff disagree on DNR status during arrest, open its explanationCommunication failure

Perioperative death

Perioperative deathAttribution
Perioperative death, commonest to rarest cause, open its explanationIllness, surgery, anaesthesia contributing, anaesthesia alone

Report a problem with card 14: Errors and incidents by type

Study design and its measures

15 / 24

Design follows how groups were formed; each measure counts one thing: risk, odds or prevalence.

How the study was run

How the study was runDesign
Exposure‑defined groups followed to outcome, open its explanationCohort study
Exposure recorded beforehand, outcome analysed later, open its explanationRetrospective cohort study
Cases versus unaffected controls, past exposure compared, open its explanationRetrospective case‑control study

What is counted

What is countedMeasure
Cohort or trial versus case‑control study, open its explanationRelative risk vs odds ratio only; 1.0: no association
Drug preventing death without cure, open its explanationRaises prevalence; fewer new cases, cure or shorter illness lowers

Report a problem with card 15: Study design and its measures

Describing data

16 / 24

Centre is mean, median or mode; spread is range or standard deviation; name the one wanted.

Description

DescriptionMeasure
Most frequent value in a data set, open its explanationMode
Middle value of data ranked low to high, open its explanationMedian, not mean or mode
Spread from smallest to largest value, open its explanationRange: largest minus smallest; sort first

Data set

Data setValue
One clear most‑frequent value, or tied leaders, open its explanationOne leader: unimodal; tied: bimodal or polymodal
Roughly normal data: interval holding 95%, open its explanationMean minus 2 standard deviations (SD) to mean plus 2 SD

Report a problem with card 16: Describing data

Part 3 · SituationsWhat now2 cards · about 1 min

  1. 18Unsafe practice by a colleague
  2. 19Exposure and spread on the ward

Unsafe practice by a colleague

18 / 24

A colleague putting a patient at risk: protect the patient now, then speak up or escalate.

Colleague's actionWhat you do
Senior breaks asepsis before central line insertion, open its explanationState safety concern directly, now, before insertion proceeds
Refused drug given covertly, concealment requested, open its explanationStop it, then disclose and report
Nurse refuses HIV care, fearing infection, open its explanationWilling colleague takes over; explain precautions; inform head nurse
Colleague's unsafe health condition, denied when raised, open its explanationReport to responsible authority, usually head of department

Report a problem with card 18: Unsafe practice by a colleague

Exposure and spread on the ward

19 / 24

Act on exposure or spread at once: report a sharps injury, enforce staff hand hygiene.

Event on the wardFirst action
Needle‑stick or sharps injury to staff, open its explanationReport to occupational health at once; file incident report
Testing source and worker after sharps injury, open its explanationOccupational health orders it after the report
Meticillin‑resistant Staphylococcus aureus (MRSA) cluster on a ward, open its explanationEnforce staff hand hygiene first

Report a problem with card 19: Exposure and spread on the ward

Part 4 · Conditions and mechanismsWhy it is true4 cards · about 2 min

  1. 20The World Health Organization (WHO) surgical safety checklist
  2. 21Infection precautions
  3. 22Occupational hazards
  4. 23What ranks highest

The World Health Organization (WHO) surgical safety checklist

20 / 24

Sign in before induction, time out before incision with the surgeon present; neither replaces the other.

Sign in, before induction

Sign in, before inductionItem checked
Identity and consent, open its explanationConfirm identity, site marking, procedure and consent
Equipment, open its explanationAnaesthesia machine and drug check; working pulse oximeter
Risk review, open its explanationKnown allergy, airway or aspiration risk, blood‑loss risk

Time out

Time outWhen and who
Timing, open its explanationAfter induction, just before incision; sign‑in cannot replace it
Surgeon not yet present, open its explanationDo not start; wait for the surgeon

Report a problem with card 20: The World Health Organization (WHO) surgical safety checklist

Infection precautions

21 / 24

Each precaution has a fixed form: five moments, gown and gloves, fit-tested respirator, fresh propofol set.

PrecautionWhat it requires
WHO hand hygiene moments, open its explanationBefore contact, asepsis; after fluids, contact, surroundings; not after asepsis
Contact precautions, open its explanationGown and gloves, donned on entry, every hands‑on contact
COVID intubation, open its explanationFit‑tested N95 respirator; eye protection, gown and gloves
Propofol infusion set, open its explanationChange with each new vial; never beyond 12 hours

Report a problem with card 21: Infection precautions

Occupational hazards

22 / 24

Know each occupational hazard by its likeliest harm, main source, exposure limit or warning sign.

Exposure

ExposureLikeliest harm or main source
Percutaneous sharps injury, non‑immune worker, open its explanationHepatitis B, the likeliest infection
Hepatitis C or HIV after sharps injury, open its explanationMuch lower risk than hepatitis B
Radiation in interventional radiology suite, open its explanationScatter from the body; cut by distance, shielding, time

Hazard

HazardExposure limit
Theatre nitrous oxide (NIOSH), open its explanation25 ppm time‑weighted average, with or without volatile
Occupational noise, open its explanation90 dB across an 8‑hour day

Sign in a colleague

Sign in a colleagueWhat it suggests
Works alone, refuses breaks, long sleeves, reduced libido, open its explanationSubstance misuse; expect denial when confronted

Report a problem with card 22: Occupational hazards

What ranks highest

23 / 24

Learn what the evidence ranks high for each list; vivid or notorious choices mislead.

The listWhat ranks high
American Society of Anesthesiologists (ASA) closed‑claims injuries, 2005‑2014, open its explanationDeath (30%); nerve damage (21%) second
Highest awareness risk: anaesthesia kept deliberately light, open its explanationMajor trauma, then cardiac surgery, then caesarean section
Commonest research misconduct, open its explanationPlagiarism, not fabrication or falsification
Among the strongest predictors of a further fall, open its explanationA previous fall; ask about falls on admission

Report a problem with card 23: What ranks highest

TrapsCheck these before you finish1 card · about 2 min

  1. 24Traps

Traps

24 / 24

The tempting call is the familiar or reassuring one; the sources name another.

TemptingRight call
Zero reported errors means safe culture, open its explanationLikely under‑reporting, not proof of safety culture
Inform the senior only, open its explanationDisclose fully to patient or family; senior leads
Visitor fall not the hospital's responsibility, open its explanationTreat the injury and file an incident report
Signed consent form makes it legal, open its explanationConsent invalid; re‑consent after disclosing alternatives
Delay surgery for the guardian's consent, open its explanationLife/organ threat: two specialists document; non‑urgent: facility committee
Wait for the absent father, open its explanationUnder 15: next available guardian; mother ranks third
Reverse the DNR for theatre, open its explanationOperate if it serves goals; DNR stays until reviewed
Treating consultant plus senior registrar sign, open its explanationSaudi: three physicians, at least one consultant; no family consent
Doctor's lack of experience, open its explanationCommunication failure, spread by unclear code‑status record
Repeat all tests after declaration, open its explanationNotify organ procurement organisation; keep supporting organs
Wife decides on donation, open its explanationThe family as a whole; no member ranked
Take drug‑company fee and disclose it, open its explanationRefuse personal payment; only institution accepts grants
Let senior continue, discuss later, open its explanationVoice the asepsis breach to him now, before insertion
Order HIV, hepatitis B and C on source, open its explanationReport to occupational health and file incident report
Surgical mask for COVID intubation, open its explanationFit‑tested N95 respirator, eye protection, gown and gloves
Not harmful after full recovery, open its explanationHarmful incident, even an expected complication
Cohort study for an existing disease cluster, open its explanationRetrospective case‑control study
Chi‑square for comparing two group means, open its explanationUnpaired t‑test
Skip time out after sign‑in, open its explanationTime out still needed, surgeon present, before incision
Acceptable because consent was given, open its explanationAlso needs benefit over harm, scientific justification, minimised risk

Report a problem with card 24: Traps

QuizCheck yourself23 practice scenarios · one to a screen

QuizCheck yourself23 practice scenariosAnswers checked against the books and guidelines.

Sheet 10 · Safety & Ethics24 / 24

That is Safety & Ethics, all 24 cards.

Your answers:

Back to the sheets

The 24 rules

One rule per card, in the sheet's order. Tap one to open its card.

Core rulesRead these first

  1. 01 · Valid consentValid consent needs a capable patient, told the alternatives, agreeing freely by word or gesture.
  2. 02 · Truth and disclosureTell the truth: disclose every error and never deceive a patient, even at a guardian's request.
  3. 03 · Reporting incidentsReport every incident, harmful or not, patient or visitor; analyse systems, not people; silence means under-reporting.

Part 1 · DecisionsWhat to do

  1. 04 · The capable adult's consentA capable adult decides: accept his refusal; postpone and explain when he has not understood.
  2. 05 · Consent without capacityPatient unable to decide: elective waits; a minor's guardian in order; an emergency needs two specialists.
  3. 06 · Demands and requestsClinical need and the law decide, not fame, insurance, your shift or the request itself.
  4. 07 · Team communicationStructure team communication: daily goals at rounds, face-to-face handover, one leader who listens.
  5. 08 · Do-not-resuscitate (DNR) orders and the end of lifeA DNR is signed by rule and reviewed deliberately, never dropped automatically; death is never hastened.
  6. 09 · Brain death and organ donationOnce brain death is declared, notify the organ procurement organisation; donation consent comes from the family.
  7. 10 · Called to courtFacing court: gather records and notes, never alter them, discuss only with your lawyer.
  8. 11 · Safety and quality programmesFit the fix to the need: assess hazards first, then choose the intervention or tool.
  9. 12 · Drug company offersA company's offer never decides: refuse personal payments and gifts; judge its drugs on evidence.
  10. 13 · Research ethicsResearch needs more than consent: benefit over harm, sound science, and protection where consent is weakened.

Part 2 · RecognitionWhat it is

  1. 14 · Errors and incidents by typeClassify each event by its cause and whether harm reached the patient, not by who erred.
  2. 15 · Study design and its measuresDesign follows how groups were formed; each measure counts one thing: risk, odds or prevalence.
  3. 16 · Describing dataCentre is mean, median or mode; spread is range or standard deviation; name the one wanted.
  4. 17 · Tests and P valuesChoose the test by data type and groups; a P value speaks to chance, never size.

Part 3 · SituationsWhat now

  1. 18 · Unsafe practice by a colleagueA colleague putting a patient at risk: protect the patient now, then speak up or escalate.
  2. 19 · Exposure and spread on the wardAct on exposure or spread at once: report a sharps injury, enforce staff hand hygiene.

Part 4 · Conditions and mechanismsWhy it is true

  1. 20 · The World Health Organization (WHO) surgical safety checklistSign in before induction, time out before incision with the surgeon present; neither replaces the other.
  2. 21 · Infection precautionsEach precaution has a fixed form: five moments, gown and gloves, fit-tested respirator, fresh propofol set.
  3. 22 · Occupational hazardsKnow each occupational hazard by its likeliest harm, main source, exposure limit or warning sign.
  4. 23 · What ranks highestLearn what the evidence ranks high for each list; vivid or notorious choices mislead.

TrapsCheck these before you finish

  1. 24 · TrapsThe tempting call is the familiar or reassuring one; the sources name another.

Review the rules

Bookmarks

All cards

Your answers:

The coverThe end

Explanation

Why

The trap

Sources

In the reference: evidence and cluesReport