Learning From the Anesthesia Incident Reporting System

July 1, 2024
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The practice of anesthesia involves the administration of powerful drugs to induce unconsciousness, manage pain, and support vital functions during surgery. Despite advancements in technology and clinical practices, anesthesia-related incidents can and do occur. To mitigate these risks and enhance patient safety, the Anesthesia Incident Reporting System (AIRS) was created to support the collection, analysis, and dissemination of information about anesthesia-related incidents, facilitating continuous learning and improvement in the field.

The Anesthesia Incident Reporting System is designed to capture data on adverse events, near misses, and any other anomalies related to anesthesia. By aggregating data from numerous incidents, AIRS helps identify common patterns and trends that might not be apparent from isolated cases. This can highlight areas where systemic improvements are needed. Understanding the underlying causes of incidents is crucial for preventing recurrence—AIRS facilitates detailed analyses to uncover deeper issues. The insights gained from the Anesthesia Incident Reporting System are then used to drive learning for anesthesia professionals. This ensures that past lessons are incorporated into future practice. Additionally, data from AIRS can inform the development of new policies and protocols, ensuring they are based on real-world evidence and address identified risks effectively 1,2.

An effective incident reporting system such as AIRS relies on several key components. For the system to be effective, healthcare providers must feel safe reporting incidents without fear of punishment. This spurs comprehensive reporting and ensures that a wide range of data is captured. In addition, protecting the identity of reporters and patients involved in incidents is crucial. Comprehensive documentation of incidents, including the context, sequence of events, and contributing factors, is vital. This allows for a thorough analysis and greater understanding of how and why incidents occur. In parallel, providing feedback to those who report incidents and communicating findings to the wider anesthesia community ensures that lessons are shared and applied broadly 3,4.

Several case studies and examples illustrate the value of learning from the Anesthesia Incident Reporting System.

Medication Errors

Analysis of AIRS data has revealed that medication errors, such as incorrect drug administration or dosing, are a relatively common type of adverse incident in anesthesia. By understanding the circumstances that lead to these errors, such as look-alike packaging or unclear labeling, strategies can be implemented to reduce their occurrence. This might include implementing barcode scanning or standardized labeling protocols 5,6.

Airway Management

Incidents related to airway management are another significant concern. Reports from AIRS have highlighted issues such as difficult intubations and unanticipated airway obstructions. Training programs emphasizing advanced airway management techniques and simulation-based education have been developed in response to these findings 7–9.

Equipment Malfunctions

Data from AIRS have identified equipment malfunctions as a frequent contributor to anesthesia-related incidents. This has led to improved maintenance schedules, regular equipment checks, and the development of more reliable and user-friendly anesthesia machines 9,10.

The impact of the Anesthesia Incident Reporting System on patient safety cannot be overstated. By fostering a culture of continuous learning and improvement, AIRS has helped reduce preventable anesthesia-related complications. Healthcare facilities that actively engage with AIRS data often report lower rates of adverse events and higher levels of staff confidence in managing anesthesia safely 11,12.

The Anesthesia Incident Reporting System represents a critical tool in the ongoing effort to enhance patient safety in anesthesia care. By capturing detailed data on incidents, facilitating root cause analysis, and informing education and policy development, AIRS helps healthcare providers learn from past experiences and implement effective strategies to prevent future incidents.


1.        AQI – Anesthesia Quality Institute. Available at: https://www.aqihq.org/airsIntro.aspx. (Accessed: 20th June 2024)

2.        Anesthesia Incident Reporting Systems – Anesthesia Services for Indiana. Available at: https://www.anesthesiaservicesin.com/anesthesia-incident-reporting-systems/. (Accessed: 20th June 2024)

3.        The Anesthesia Incident Reporting System (AIRS) – Anesthesia Patient Safety Foundation. Available at: https://www.apsf.org/article/the-anesthesia-incident-reporting-system-airs/. (Accessed: 20th June 2024)

4.        Saad, R. & Hanna, J. S. Reporting: Mandatory and Voluntary Systems, Legal Requirements, Anesthesia Quality Institute, and Physician Quality Reporting System. Case Stud. Clin. Psychol. Sci. Bridg. Gap from Sci. to Pract. 1–7 (2023). doi:10.1093/MED/9780197584521.003.0372

5.        Mutair, A. Al et al. The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines 8, 46 (2021). doi: 10.3390/medicines8090046

6.        Anesthesia Incident Reporting System (AIRS): Case 2021-3: All Orders Are Not Alike. ASA Monit. 85, 22–22 (2021).

7.        Avva, U., Lata, J. & Kiel, J. Airway Management – StatPearls – NCBI Bookshelf. StatePearlsPublishing (2021).

8.        Apfelbaum, J. L. et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology (2022). doi:10.1097/ALN.0000000000004002

9.        Anesthesia Incident Reporting System (AIRS) Case 2022-08: It’s All About the Airway. What Would You Do? ASA Monit. 86, 10–11 (2022).

10.      McIntyre, J. W. R. Anesthesia equipment malfunction: Origins and clinical recognition. Can. Med. Assoc. J. (1979).

11.      Arnal-Velasco, D. & Barach, P. Anaesthesia and perioperative incident reporting systems: Opportunities and challenges. Best Practice and Research: Clinical Anaesthesiology (2021). doi:10.1016/j.bpa.2020.04.013

12.      Bielka, K. et al. Critical incidents during anesthesia: prospective audit. BMC Anesthesiol. (2023). doi:10.1186/s12871-023-02171-4