Whilst modern anaesthesia is considered safe, complications are nevertheless not uncommon and continuing efforts are directed to improve patients’ safety. Very serious avoidable events are called ‘never’ events, but sadly do occur, not infrequently. There are often may factors leading to patient risk including both human factors (fatigue and working under pressure) and organisational factors (poor working environment, faulty equipment, monitoring, and IT systems)

Risk should be assessed preoperatively for major surgery and/or patients with comorbidities. There are a number of scoring and prediction models to assist in this process.

Moreover, there are various check lists and care bundles designed to reduce risk further (e.g. WHO checklist, sepsis bundle etc).

In the preoperative period patient optimization is key, treating intercurrent diseases (including anaemia) and assisting in reducing smoking and alcohol intake, and optimizing nutrition. Intraoperatively there is great focus is on safety, including the recognition of an oesophageal intubation. Other areas are the prevention of end organ injury from hypotension, lung protection, and the prevention of postoperative confusion and delirium. In the postoperative period, the focus is on promoting return to normal function, with appropriate analgesia, thromboprophylaxis, oxygen therapy, fluid therapy as required.

In the very high risk setting, lesser surgery or indeed no surgery at all may be the best option for a patient.