Abstract Background: Intraoperative arrhythmia is a common and potentially serious complication. during general anesthesia, ranging from benign rhythms to life-threatening events. Its occurrence is influenced by a complex interplay of patient-related, anesthesia-related, and surgical factors. While international data exists, there is a significant lack of context-specific evidence on its incidence and associated factors within the Ethiopian healthcare setting and to fill the existing knowledge gap for optimizing intraoperative management practice. Objective: to determine the incidence and identify the factors associated with intraoperative arrhythmia in patients undergoing general anesthesia at Tibebe Ghion Specialized Hospital, Northwest Ethiopia. Methods: A hospital-based prospective cohort study was conducted from September 1, 2025, to January 30, 2025. A sample of 165 patients undergoing general anesthesia with standard monitoring, including continuous electrocardiogram (ECG), was selected using consecutive sampling. Data on socio-demographics, comorbidities, preoperative status, anesthesia details, and surgical factors were collected using a structured checklist. The primary outcome was the incidence of any intraoperative arrhythmia. Data was analyzed using SPSS version 27; binary and multivariable logistic regression was employed to identify factors significantly associated with arrhythmias at a p-value < 0.05. Results: In this cohort, approximately one in five patients (19.4%) experienced intraoperative arrhythmia, while the majority (80.6%) did not. Multivariable binary logistic regression analysis demonstrated that worsening of American Society of Anesthesiologists (ASA) status (OR 0.021, p = 0.001, 95% CI 0.002 – 0.19) and Prolonged surgical duration (OR 0.130, p < 0.001, 95% CI 0.046–0.370) was associated with significantly increased risk of arrhythmia. Conclusion and Recommendation: Arrhythmias can occur anytime during the procedure; hence, Comprehensive preoperative evaluation, prompt recognition, and response to arrhythmic events And interdisciplinary collaboration throughout the perioperative period is essential. In this study patients with higher or worsening ASA class are at greater risk of anticipating arrhythmias. Instead of reacting to emergencies, ensuring functioning monitoring equipment before induction and preparing anti-arrhythmic medications are important.