December 2004 Bulletin

JCAHO issues Sentinel Event Alert on anesthesia awareness

The phenomenon of anesthesia awareness, also called unintended intraoperative awareness, occurs under anesthesia when a patient becomes cognizant of some or all events during a surgical procedure and has direct recall of those events. Because of the routine use of paralytics during general anesthesia, the patient is often unable to communicate with the surgical team if this occurs.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) estimates that anesthesia awareness affects an estimated 20,000 to 40,000 patients each year. Although that figure represents only one to two cases in every 1,000 instances when general anesthetics are administered, the experience is traumatic for those patients who do become aware. Patients undergoing cardiac, obstetric and major trauma surgeries are at proportionately higher risk for anesthesia awareness.

To reduce the risk of anesthesia awareness, JCAHO has issued a Sentinel Event Alert. The Alert is designed to provide practical advice to health care organization leaders and health care professionals to help prevent and manage anesthesia awareness when it occurs. Specific recommendations include:

  1. Developing and implementing an anesthesia awareness policy that addresses the following:

  2. Assuring access to necessary counseling or other support for patients who are experiencing posttraumatic stress syndrome or other mental distress.

JCAHO notes that anesthesia awareness cannot always be prevented. As a consequence, health care practitioners must be prepared to acknowledge and manage the occurrence of anesthesia awareness with compassion and diligence.

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