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Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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A Look at The Joint Commission

Preanesthesia Assessments Allow Safer Surgery for Patients and Surgeons

Lenworth M. Jacobs Jr., MD, MPH, FACS

Lenworth M. Jacobs Jr., MD, MPH, FACS

March 6, 2024

One of the most common fears surgeons hear from patients who are about to enter surgery is that they will experience a severe complication with anesthesia and won’t wake up.

While exceedingly rare, these types of complications can happen. Alternatively, there is a risk that they will wake up and experience some level of consciousness during surgery. For surgeons, it is shocking and distressing to have a patient describe some part of the procedure or recall that they felt discomfort or pain during the surgery. These impressions can remain with the patient for long periods of time and cause significant emotional distress.

Estimates show that among 20 million anesthetics administered, 26,000 incidents of a patient experiencing some level of awareness during surgery—such as pain, auditory perceptions, the sensation of the endotracheal tube, or dreaming during surgery—occur in the US each year.1

These errors with anesthesia can have long-term impacts on patients, well past the initial postoperative period. After experiencing awareness during surgery, patients reported significant postoperative distress related to feeling unable to communicate, unsafe, terrified, abandoned, and betrayed, resulting in many patients developing post-traumatic stress disorder.2

Not only can these events cause long-term emotional harm for patients, but they also can result in a mental toll on the surgeon. One study found a strong connection between reported major medical errors and degree of burnout, mental quality of life, and depression for surgeons.3 These findings suggest that preventing anesthesia-related errors is in the interest of patients and surgeons.

The Preanesthesia Assessment

Anesthesia-related events can happen if the correct precautions aren’t taken prior to surgery. Surgeons and anesthesiologists must work together to ensure these “never events” never happen.

Surgeons and anesthesiologists have tools at their disposal to prevent these kinds of errors. Preanesthesia assessments allow the surgery team to identify perioperative risks as well as implement interventions to mitigate them. Preanesthesia assessments, conducted by an individual qualified to administer anesthesia, provide an opportunity to build rapport between the anesthetist and patient, while reducing patient anxiety about the procedure.4

Elements of a Preanesthesia Assessment

A thorough preanesthesia assessment is critical to reducing risks associated with anesthesia and developing an anesthesia plan.

While required by The Joint Commission, the preanesthesia assessment is an underutilized tool. In 2022, The Joint Commission found that approximately one-in-five hospitals surveyed were not in compliance with this requirement, either missing elements of a preanesthesia assessment or not performing an assessment at all.5 Surgical teams should have the proper policies and procedures in place to ensure the assessment occurs according to requirements.

According to the American Society of Anesthesiologists (ASA), a preanesthesia assessment should involve:6

  • Reviewing the patient’s medical history, including anesthesia, drug and allergy history, and a physical examination
  • Formally assessing anesthesia risks and identifying potential problems, particularly those that may suggest complications or contraindications to the planned procedure
  • Collecting additional preanesthesia data or information, such as stress tests or other specialist consultations
  • Discussing risks and benefits of anesthesia
  • Obtaining informed consent
  • Developing a plan for the patient’s anesthesia care, including the discussion and potential use of an amnestic agent

A proper preanesthesia assessment should be conducted within 48 hours of the day of surgery. The ASA provides additional guidance on preanesthesia assessments and how they differ from a general preoperative assessment as well as example scenarios on its website.

After the Preanesthesia Assessment

Surgeons should discuss the findings of a preanesthesia assessment with the anesthesiologist and potentially other specialists to determine impacts to the surgery plan. Surgeons may have to modify their plans to ensure the patient is safe and the procedure is in the patient’s best interest.

If an error occurs, whether related to anesthesia or another part of the surgery, best practice for surgeons is to have an immediate conversation with the patient and his or her family about what happened and how it was resolved. These conversations are undoubtedly challenging, but they are necessary to foster trust between surgeons and patients.


The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

Dr. Lenworth Jacobs is a professor of surgery and professor of traumatology and emergency medicine at the University of Connecticut in Farmington and director of the Trauma Institute at Hartford Hospital, CT. He is Medical Director of the ACS STOP THE BLEED® program.

  1. Sebel PS, Bowdle TA, Ghoneim MM, Rampil IJ, et al. The incidence of awareness during anesthesia: A multicenter United States study. Anesth Analg. 2004;99(3):833-839. 
  2. Osterman JE, Hopper J, Heran WJ, Keane TM, et al. Awareness under anesthesia and the development of posttraumatic stress disorder. Gen Hosp Psychiatry. 2001;23(4):198-204.
  3. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
  4. Omole OB, Torlutter M, Akii AJ. Preanaesthetic assessment and management in the context of the district hospital. S Afr Fam Pract. 2021;63(1):e1-e7.
  5. The Joint Commission. Joint Commission Perspectives®. 2024;44(1).
  6. American Society of Anesthesiologists. ASA Committee on Economics. Distinguishing between a pre-anesthesia evaluation and a separately reportable evaluation and management service. Available at: https://www.asahq.org/quality-and-practice-management/managing-your-practice/timely-topics-in-payment-and-practice-management/distinguishing-between-a-pre-anesthesia-evaluation-and-a-separately-reportable-evaluation-and-management-service. Accessed January 2, 2024.