A study of 1,024 postoperative deaths in Baltimore hospitals during a period of 5 1/2 years (1953 to 1959) indicated that anesthesia was the principal cause of death in 6.3% of the cases and a contributing factor in 12.9%. The mortality rate associated with anesthesia was 4 per 10,000 operations. The rate was significantly higher for males (7.1) than for females (2.7). Errors in preoperative preparation and medication of the patient and selection of the anesthetic agent accounted for about one-fourth of the deaths. Faulty management of the anesthesia was the principal cause of death in more than 50% of the cases. The remaining deaths were considered the result of improper resuscitation measures and postoperative medication and management. One-half of all the deaths occurred in the patients' rooms; one-half occurred within seven hours after beginning anesthetization.
Phillips OC, Frazier TM, Graff TD, DeKornfeld TJ. The Baltimore Anesthesia Study CommitteeReview of 1,024 Postoperative Deaths. JAMA. 1960;174(16):2015–2019. doi:10.1001/jama.1960.03030160001001
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