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Safety and Quality

Aim: To promote global standards in anaesthesiology

Objective 1: To promote and maintain the International Standards for the Safe Practice of Anaesthesia around the globe

Objective 2: To provide guidance concerning the professional wellbeing of anaesthesiologists


International Standards

The programme aims to continuously develop the International Standards for a Safe Practice of Anaesthesia (Merry et al). The latest version was updated in 2010:

International Standards for a Safe Practice of Anaesthesia

These standards are recommended for anaesthesia professionals throughout the world. They are intended to provide guidance and assistance to anaesthesia professionals, their professional societies, hospital and facility administrators, and governments for improving and maintaining the quality and safety of anaesthesia care. They were adopted by the World Federation of Societies of Anaesthesiologists on the 13th June 1992, and revisions were ratified on 5th March 2008 and on 19th March 2010.

The WFSA has developed an online questionnaire on anaesthesia capacity based on the international standards in order to gather data about anaesthesia workforce, equipment, medicines and practices at facility level. If you would prefer to complete the questionnaire in Microsoft Word, please download it here and send it back to programmes@wfsahq.org.

The questionnaire can also be used as a checklist to determine levels of anaesthestic capacity, and provide guidance for improving or maintaining standards for the safe practice of anaesthesia. Click the links below for English, French, Spanish, Indonesian and Hindi versions.

1. International Standards - Checklist (English)   2. Normas Internacionales - lista de verificación en Español   3. Normes internationales - Liste de contrôle en français   4. Standar Internasional - Kuesioner Kapasitas Kemampuan Anestesia   5. अंतरराष्ट्रीय मानक - निश्चेतना क्षमता प्रश्नावली 

It can be used (for example) by health departments to conduct self-assessments or by NGOs to assess country or regional capacity and make recommendations accordingly. 

Guidelines for tendering for anaesthesia machines

As the supply of electricity and compressed gases varies from location to location the WFSA has developed guidelines for those seeking to tender for and purchase anaesthesia machines. Following ISO standards (which the WFSA helped to develop) this short document and flowchart guides the decision maker to the ISO standard appropriate for their environment.


WFSA Partnership with the Red Cross

 The WFSA and the International Committee of the Red Cross (ICRC) are working together to ensure safe anaesthesia for patients admitted to ICRC facilities. The partnership aims to create an anaesthesia forum for questions from the field, update ICRC's clinical protocols, course materia and field sets, and establish mechanisms for the deployment of qualified anaesthesiologists. Amongst the first products worked on by the ICRC-WFSA Liaison Group is the ICRC's Anaesthesia Handbook which provides invaluable guidance for anaesthesia providers working in austere environments.

ICRC Handbook cover

ICRC is actively recruiting anaesthesiologists for short missions (average is 3 months). Find out more about working for ICRC as an anaesthetist here

The WFSA also supports the ICRC's Health Care in Danger project which was launched in November 2011 during the 31st Red Cross Red Crescent International Conference. 

Armed conflict and other emergencies generate additional health care burdens for the people affected, especially the wounded and sick. At the same time, it has been found that it is during these times that health care is most inaccessible and insecure. This situation represents a negation of the right of all wounded combatants and civilians to have access to health care during armed conflict as laid down in international humanitarian law and international human rights law.

The Health Care in Danger project is a Red Cross and Red Crescent Movement initiative aiming to improve security and delivery of impartial and efficient health care in armed conflict and other emergencies. 

For more information about the project please click here.

Occupational Well-Being

This project concerns the occupational health of anaesthesiologists, including the publication and promotion of the book "Occupational Well-Being of Anaesthesiologists". Edited by Dr Gastao Duval Neto, Chair of the WFSA's Professional Wellbeing Committee, and published by the Brazilian Society of Anaesthetists, the book brings together academics and practitioners concerned with the very real issues facing the health of anaesthesiologists around the world.

The publication aims to stimulate the development of effective action on the part of world entities involved with anaesthesiology, in favour of the occupational health of anaesthesiologists and safety of their patients. For anaesthesiologists themselves it aims to promote awareness, conscious that awareness of any problem is the first step towards its solution.

Available in English, Spanish, Chinese and Portuguese this is a "must read" for anaesthesiologists and those with whom they live and work.

 Occupational wellbeing front cover English  Occupational wellbeing front cover Spanish  Occupational wellbeing front cover Chinese  Occupational wellbeing front cover PORTUGESE

 Read the AAGBI's March 2016 article entitled 'Fatigue, stress and death in training' here on page 30.



 Burnout has become a critical and global issue facing medical practitioners today - anaesthesiologists are no exception. A national survey published in the Archives of Internal Medicine in 2012 reported that US physicians suffer more burnout than other American workers. 45.8% of physicians were experiencing at least 1 symptom of burnout: loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. In a recent survey, when anaesthesiologists were given the same criteria, 42% responded that they were burned out and 58% said that they were not. They were tied for fourth place in burnout rate with internists, general surgeons, and obstetricians/ gynaecologists (Peckham, 2013).

WFSA has started an important study in this area with the aim of identifying work that can be developed at a global level and to help us to write guidelines to support anaesthesiologists living with or at risk of burnout.

This tool, a short questionnaire, can help you check yourself for burnout. It helps you look at the way you feel about your job and your experiences at work, so that you can get a feel for whether you are at risk. 




WFSA is a co-founder, funder and supporter of Lifebox Foundation, an independent charity focused on making surgery safer in low-resource countries. More than 70,000 operating rooms worldwide lack access to pulse oximetry, and the risk of anaesthesia mortality can be as high as 1 in 133.

Lifebox provides essential monitoring and training in the World Health Organization (WHO) Surgical Safety Checklist – an intervention proven to reduce complications and mortality in the OR by more than 40%. Watch the Lifebox video here for a genuine insight into the function and impact of the checklist. 

With support from WFSA and its members around the world, Lifebox has put more than 8000 pulse oximeters into the hands of anaesthesia providers who need them, trained thousands in safer surgical practice, and helped to safeguard millions of patient lives.

Do you always have oximeters available when delivering anaesthesia? If no, are you happy for Lifebox to work with you to provide oximeters and training?

WFSA member societies in low-resource settings are encouraged to apply for this essential equipment and training online here, and all members are invited to play a part in addressing the fastest-growing global health crisis today: unsafe surgery and anaesthesia. 

WFSA also recommends the Student Toolkit developed by Lifebox. This is packed with information about global surgery, how Lifebox is making surgery safer, and how you can get involved. Click below.

                                         Lifebox Screenshot 2014-04-04 14.11.15 2


Finally we thoroughly recommend taking a look at the Lifebox Annual Review 2014 which provides a fabulous insight into their work over the year. 

Other Recommended Reading (Safety)

We also recommend reading this excellent article in the June 2014 journal of the Anesthesia Patient Safety Foundation written by David Whitaker and David Wilkinson: 


Other Recommended Reading (Wellbeing)

Other Bibliography recommended by the Professional Wellbeing Committee of WFSA


Gazoni FM, Amato PE, Malik ZM, and Durieux ME; Anesth Anal; 2012; vol. 114: 596-602.

Synopsis: This paper presents the results of a postal survey sent to 1200 American Society of Anesthesiologists members concerning the effect on their emotions and careers of a perioperative catastrophe. 659 anesthesiologists responded and of those 84% had been involved in at least one unanticipated death or serious perioperative injury of a patient during their career. Some 70% of anesthesiologists, having had a perioperative catastrophe, indicated significant emotional responses including guilt, anxiety, and reliving the event, with the majority requiring time to recover emotionally from the event and 19% indicating that they never fully recovered. 5% turned to substance abuse for self-medication of their stress, while as many as 10% considered changing their career. The conclusion was that due to the profound and in some cases lasting impact of a perioperative catastrophe, that protocols and guidelines need to be developed for support of the practitioner following the occurrence of an adverse event.

To read the full article click here


De Oliveira, GS, Chang R, Fitzgerald PC, Almeida MD, Castro-Alves LS, Ahmad S, McCarthy RJ; Anesth Anal; 2013; vol. 117: 182-192.

Synopsis: This paper evaluated the prevalence of burnout and depression in anesthesiology residents by sending a survey to 2773 anesthesiology residents in the United States. There were five parts to the survey: 1) general demographic data, 2) Maslach burnout inventory, 3) Harvard depression scale, 4) 10 questions to evaluate best practice in anesthesiology, and 5) 7 questions to evaluate self reporting of errors. 1508 of the residents responded. There was a high burnout risk in 41% of the respondents and an increased risk was associated with a work week >70 hours, >5 alcohol drinks a week, and female gender. 22% screened positive for depression with the same factors that increased burnout risk but with the additional factor of smoking. 17% of all respondents scored high for both depression and burnout risk. Residents at high risk for burn out and depression had poorer scores for following the best anesthesia practices. In addition, 33% of the high risk group reported making multiple medication errors in the year before the survey, compared to only 0.7% in the low risk responders. The conclusions were that burnout, depression and suicidal ideation were prevalent in anesthesiology residents and that a secondary effect of this condition may adversely affect patient safely and quality of care.

To read the full article click here


Astrid Richter , Petya Kostova , Xaver Baur , Ralf Wegner - Int Arch Occup Environ Health. 2014 Feb;87(2):205-15. doi: 10.1007/s00420-013-0849-x. Epub 2013 Feb 20.


The present study is a 10-year comparison (1997 vs. 2007) of occupational and health aspects before and after the implementation of the European Working Time Directive on German hospital physicians. A major focus is whether the changes in working conditions are accompanied by a lower risk for burnout.

Changes in working conditions in accordance with the European Working Time Directive are not accompanied by reduced strain and risk of burnout for physicians. Rather, our data argue for greater intensification in work, especially for senior physicians. Further studies are suggested in order to explore interventions for a sustainable improvement in the working conditions of physicians.

For a more detailed abstract and to purchase this article click here


A. J. Montgomery, C. Bradley, A. Rochfort and E. Panagopoulou - Occupational Medicine 2011;61:490–497 Advance Access publication on 4 July 2011 doi:10.1093/occmed/kqr098


The present study is a 10-year comparison (1997 vs. 2007) of occupational and health aspects before and after the implementation of the European Working Time Directive on German hospital physicians. A major focus is whether the changes in working conditions are accompanied by a lower risk for burnout.

Changes in working conditions in accordance with the European Working Time Directive are not accompanied by reduced strain and risk of burnout for physicians. Rather, our data argue for greater intensification in work, especially for senior physicians. Further studies are suggested in order to explore interventions for a sustainable improvement in the working conditions of physicians

To read the full article click here 


Chia, A. C. L. ; Irwin, M. G. ; Lee, P. W. H. ; Lee, T. H. W. ; Man, S. F. - Anaesthesia and Intensive Care, Nov, 2008, Vol.36(6), p.855(8).


A postal survey was sent to anaesthetic trainees in Hong Kong and Victoria, Australia to compare work-related stress levels. Demographic data were collected. Anaesthetist-specific stressors, Maslach Burnout Inventory and Global Job Satisfaction scores were used for psychological testing. The response rates from Hong Kong and Melbourne were 64 of 133 (48.1%) and 108 of 196 (55.1%), respectively. Victorian respondents were older with greater family commitments, but more advanced in fulfilling training requirements. Hong Kong respondents, being faced with both the challenge of dual College requirements, exhibited consistently higher indices of stress (P <0.001) and less job satisfaction (P <0.001). Common occupational stressors related to dealing with critically ill patients and medicolegal concerns. Higher stress scores observed in Hong Kong trainees related to service provision and a perceived lack of resources. Despite the complex nature of stress, its antecedents and manifestations, an inverse relationship between emotional exhaustion and job satisfaction was evident in correlation analysis (P <0.001). This survey suggests that stress was present in some trainees in both areas. Hong Kong trainees may benefit from local development to address mental wellbeing as being important to fulfil this highly competitive training program.

Key Words: stress, anaesthetic training, burnout, job satisfaction 

Full article only available online through purchase or subscription


Martha S Gerrity - Social Science & Medicine 52 (2) : 223, 2001


Dr. Firth-Cozens begins her paper by reviewing a broad range of research related to physicians’ stress, depression, and alcoholism (Firth-Cozens, 2001, Social Science and Medicine, 52, 215–222). She then argues that these psychological problems have a negative impact on patient care and describes the possible causes of these problems. Finally, she proposes a system of organizational and individual interventions to address these problems. Before accepting her conclusions and proposed system of interventions, an important issue should be considered. Is physicians’ well-being an important goal in and of itself, or do we need strong evidence that physician stress, depression, and alcoholism lead to poor patient care and outcomes?

Keywords:  Physicians; Psychological problems; Patient care; Response

Full article only available online through purchase or subscription

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