Most of the time, anaesthesia in the UK is practiced and delivered safely. However, emergencies or serious complications associated with anaesthesia do occur, with potentially devastating consequences for patients, their families and staff. Although anaesthetic emergencies are usually managed well, national reports consistently identify room for improvement. For example, despite high-profile cases, unrecognised oesophageal intubation still occurs in the UK, causing harm (including death) and is preventable [1].

Data from the 7th National Audit Project (NAP7) have shown anaesthesia and surgery to be very safe (risk of death during elective surgery if a patient is of ASA physical status 1–2 is around 1 in 100,000 cases) but also that life-threatening events are not that uncommon (one or more potentially serious complications in 1 in 18 cases, cardiac arrest in 1 in 3000 and close to 1 in 1000 in patients who are older and frailer) [2]. More than half of cardiac arrests are caused by low occurrence, high impact events (haemorrhage, severe bradycardia, cardiac ischaemia, isolated hypotension, hypoxaemia and anaphylaxis) [3]. Unrecognised oesophageal intubation remains an unmeasured and too prevalent problem. Care was often imperfect, being judged (when assessable) to include poor care in 40% of cases before the event and in 36% of cases overall.

It is too easy to believe that rare things do not happen to us or our patients, but this view could not be further from the truth. The approximately 24,000 cases reported to the NAP7 activity survey are comparable in volume to the annual throughput of some larger NHS sites. Based on that survey data and from NAP4 4 and NAP6, these centres would see a case of profound hypotension five times a week, two major haemorrhages a week, laryngospasm every other day, aspiration twice a month, 2–3 life-threatening anaphylactic reactions a year, eight cardiac arrests and several peri-operative deaths [2, 3]. Emergencies are happening all around us. Even if they do not happen to the patient directly under our care.

Nathanson et al. call for mandatory training to focus on low occurrence, high impact events [4]. Many of these have been the focus of previous National Audit Projects. Many may consider the view of Nathanson et al. the right thing to do, but it may not be universally popular and would represent a revolution in mandatory training in the UK. There have already been calls for significant overhauls of mandatory training [5]. What is mandatory, what is statutory and what is fruitful, do not always overlap. However, what needs to be designed, delivered and implemented must be just right; effective but not burdensome. It must be built from solid evidence and be of value and not tokenistic.

An important challenge arises regarding who should drive such a change. The Royal College of Anaesthetists takes the view that it cannot mandate the actions of its members but, conversely, it holds the baton for professional standards, and must, therefore, take a lead. The Association of Anaesthetists has a long history of promoting safety and improving standards through guidelines. We recommend that a task force is established by the College and Association. The NHS should be centrally engaged and committed. Representation from specialist societies, surgeons, patients and experts in human factors, education and implementation science will be essential. The core emergencies should be agreed on and delivery modalities tested. It must be adequately funded, and the efficacy rigorously evaluated. Lessons should be learnt from Australia and New Zealand, where such a programme already exists, and any programme should apply to the NHS and the independent sector. Only through a genuine commitment (nationally, by organisations and departments) to maintain a level of preparedness for anaesthetists, teams and departments can we manage these low occurrence, high impact events better and improve patient safety.

大多数时候，英国的麻醉是安全地进行和实施的。然而，与麻醉相关的紧急情况或严重并发症确实会发生，对患者、他们的家人和工作人员造成潜在的毁灭性后果。尽管麻醉急症通常管理良好，但国家报告一致认为还有改进的空间。例如，尽管病例备受瞩目，但英国仍会发生未被发现的食管插管，造成伤害（包括死亡）且是可以预防的 [1]。

来自第 7 个国家审计项目 （NAP7） 的数据表明，麻醉和手术非常安全（如果患者身体状况为 ASA 1-2，则择期手术期间的死亡风险约为 100,000 例中的 1 例），但危及生命的事件并不少见（每 18 例中就有 1 例出现一种或多种潜在的严重并发症， 心脏骤停的发生率为 1/3000，年龄较大和身体虚弱的患者接近 1/1000）[2]。超过一半的心脏骤停是由低发生率、高影响事件（出血、严重心动过缓、心脏缺血、孤立性低血压、低氧血症和全身性过敏反应）引起的[3]。未被发现的食管插管仍然是一个未测量且过于普遍的问题。护理往往不完美，在事件发生前 40% 的病例和 36% 的总体病例中被判断为（在可评估时）包括护理不良。

人们很容易相信罕见的事情不会发生在我们或我们的病人身上，但这种观点与事实相去甚远。NAP7 活动调查报告的大约 24,000 例病例在数量上与一些较大的 NHS 站点的年吞吐量相当。根据该调查数据以及 NAP4 4 和 NAP6，这些中心每周会出现 5 次严重低血压病例，每周 2 次大出血，每隔一天出现一次喉痉挛，每月两次误吸，每年 2-3 次危及生命的过敏反应，8 例心脏骤停和数例围手术期死亡 [2， 3]。紧急情况正在我们周围发生。即使它们没有发生在我们直接照顾的病人身上。

Nathanson 等人呼吁进行强制性培训，以关注低发生率、高影响的事件 [4]。其中许多项目一直是以往国家审计项目的重点。许多人可能认为 Nathanson 等人的观点是正确的做法，但它可能并不普遍流行，并且将代表英国强制性培训的一场革命。已经有人呼吁对强制性培训进行重大改革 [5]。什么是强制性的，什么是法定的，什么是富有成效的，并不总是重叠的。然而，需要设计、交付和实施的内容必须恰到好处;有效但不繁琐。它必须建立在确凿的证据之上，并且有价值，而不是象征性的。

关于谁应该推动这种变革，一个重要的挑战出现了。皇家麻醉师学院认为，它不能强制要求其成员的行动，但相反，它掌握着专业标准的接力棒，因此必须发挥带头作用。麻醉师协会在通过指南促进安全和提高标准方面有着悠久的历史。我们建议学院和协会成立一个工作组。NHS 应该集中参与和承诺。来自专家协会、外科医生、患者以及人为因素、教育和实施科学专家的代表将是必不可少的。应就核心紧急情况达成一致，并测试分娩方式。它必须有足够的资金，并严格评估其有效性。应该向澳大利亚和新西兰吸取经验教训，这两个国家已经有这样的计划，任何计划都应该适用于NHS和独立部门。只有通过真诚的承诺（在国家范围内、组织和部门）为麻醉师、团队和部门保持一定程度的准备，我们才能更好地管理这些低发生率、高影响的事件并提高患者安全。