An observational study of practice during transfer of patients from anaesthetic room to operating theatre

Summary We observed practice during transfer of 80 patients from anaesthetic room to operating theatre, to determine the duration of apnoea and the time without monitoring during the transfer process. Median (IQR [range]) time from disconnection of the breathing system in the anaesthetic room to the first breath in theatre was 54 (44–65 [27–196]) s, and from disconnection of the pulse oximetry probe to the first reading in theatre was 90 (74–103 [44–182]) s. In four patients (5%) arterial oxygen saturation fell to 94%, with the greatest desaturation observed 11%. The transfer process may represent a window of opportunity for the occurrence of harm or the first step in a chain of events leading to harm, and is difficult to justify on patient safety grounds.