Robert K Stoelting
Anesthesia Patient Safety Foundation
Anaesthesia was the first medical specialty to champion patient safety as specific focus.(1,2) Although reports from the 1950s through to the 1970s were anecdotal and imperfect, there was a widespread impression that anaesthesia care caused mortality in one to two patients out of every 10,000 anaesthetics. Multiple factors in the late 1970s led to significant changes in anaesthesia practice that contributed to a decrease in mortality and morbidity attributed to anaesthesia. Although the magnitude of this decrease in anaesthesia mortality is difficult to measure and anaesthesia-related adverse events still occur, it is recognised that anaesthesia for healthy patients is safer today than it was in the past.(3) An important ingredient in the anaesthesia patient safety movement was the presence of a highly visible and respected advocate, Dr Ellison C Pierce Jr.(4) In 1984, Dr Pierce, as president of the American Society of Anesthesiologists (ASA), established a new ASA Committee on Patient Safety and Risk Management, which addressed the causes of patient injury. That same year, Dr Pierce and Harvard Medical School colleagues convened the International Symposium on Preventable Anesthesia Mortality and Morbidity, which was the first organised examination of what was soon to be known as “anaesthesia patient safety”.
“No patient shall be harmed”
The Anesthesia Patient Safety Foundation (APSF) was launched in October 1985 as an independent foundation with the mission that “no patient shall be harmed by anaesthesia”. The ASA, corporate supporters and individuals provided the initial financial support that has continued to the present. The APSF Board of Directors represents a broad spectrum of stakeholders, including anaesthesiologists, nurse anaesthetists, manufacturers of equipment and drugs, regulators, risk managers, attorneys and engineers. The neutral umbrella of APSF facilitates open communications between clinicians and industry representatives about the sensitive issues of anaesthesia accidents. Unlike professional societies, APSF can bring together multiple and varied constituencies in healthcare that may disagree over economic (industry competitors) or political issues, but which all agree on the goal of patient safety.
Culture of safety
In the long term, the most important contribution of anaesthesiology and the APSF to patient safety may be the institutionalisation and legitimisation of patient safety as a topic of professional concern. APSF provides research grants (currently $150,000 per award) for projects that study patient safety related issues. When the first APSF grants were awarded in 1987, funds for patient safety research in anaesthesia were nonexistent. Since the first grants, APSF has awarded more than $3,600,000, resulting in multiple peer-reviewed publications. APSF funding and support of realistic patient simulators has contributed to the subsequent application of simulators to anaesthesia education and safety training. A new cadre of investigators and scholars owe their academic success in some part to the APSF grant programme.
Dissemination of safety information
The APSF Newsletter currently has a circulation of more than 80,000, making it the most widely distributed anaesthesia publication in the world. Rapid dissemination of patient safety information and opinions is an important contribution of the newsletter to patient safety. Other educational efforts of APSF have included co-sponsorship of a videotape series on safety topics and development of an extensive website.
The success of the anaesthesia patient safety movement was recognised in 1996 when the American Medical Association and corporate partners founded the National Patient Safety Foundation, which was structured to reflect the APSF model. Further recognition for safety efforts and leadership came to APSF in the landmark 1999 report from the Institute of Medicine on errors in medical care.(5) On 21 June, 2005, The Wall Street Journal published a front page article about the successful efforts of anaesthesiologists, the ASA and APSF to improve anaesthesia patient safety.
Patient safety successes
Human factor and resource issues have played a key role in improving anaesthesia patient safety. In 1990, APSF and the Food and Drug Administration convened an expert workshop on human error in anaesthesia practice serving to stimulate later safety advances. More recent APSF safety initiatives include support of automated information systems and standardisation of terminology for anaesthesia records. The Data Dictionary Task Force and the International Organisation for Terminology in Anaesthesia, under the sponsorship of APSF, have developed standard anaesthesia terms for use in automated information systems. Collection of real-time data gathered from the millions of anaesthetics administered annually worldwide could lead to a better understanding of best anaesthesia practices and improved patient safety.
APSF has advocated application of a systems approach to anaesthesia care based on high-reliability organisational theory. A multidisciplinary conference under the direction of APSF addressed the issues surrounding long-term outcome following anaesthesia and surgery.(2) APSF has advocated a single safety standard for surgical and anaesthetic procedures regardless or whether these occur in the hospital, ambulatory surgical unit or the physician’s office. In April 2005, APSF sponsored a conference including clinicians and industry representatives to discuss the risk of exothermic reactions in the presence of desiccated carbon dioxide absorbents. This conference resulted in recommendations regarding the use of carbon dioxide absorbents that were intended to reduce the likelihood of fires in the anaesthesia machine and breathing circuit. The revision of the ASA Standards for Basic Intraoperative Monitoring in October 2005 to include audible physiological alarms (pulse oximetry and capnography) reflected the advocacy of APSF for this change. An APSF workshop in October 2006 on safety during patient-controlled analgesia led to a report recommending consideration of continuous monitoring of oxygenation and ventilation, especially in high-risk (obstructive sleep apnoea) patients.
The goal of improving patient safety is not finished. Equipment and systems still occasionally fail and preventable human errors continue to occur. Increasing “production pressures” in anaesthesia practice in the presence of diminishing resources may threaten previously achieved gains in patient safety. Similar to aviation, improvements in anaesthesia patient safety have been achieved by a whole host of changes that made sense (were the right thing to do) and were based on an understanding of human-factor principles. Evidence from randomised trials (evidence-based medicine) may be neither appropriate nor essential for all of the interventions needed to improve patient safety.(6) Improved anaesthesia patient safety reflects doing a number of “little things” that, in the aggregate, make a big difference.(6)
- Gaba DM. Anaesthesiology as a model for patient safety in health care. BMJ 2000;320:785-8.
- Stoelting RK, Khuri SF. Past accomplishments and future directions: Risk prevention in anaesthesia and surgery. Anesthesiol Clin N Am 2006;24:235-53.
- Cooper JC, Gaba, DM. No myth: anaesthesia is a model for addressing patient safety. Anesthesiology 2002;97:1335-7.
- Pierce EC. The 34th Rovenstine lecture: 40 years behind the mask: safety revisited. Anesthesiology 1996;84:965-75.
- Kohn LT, et al. To err is human – building a safer health system. Washington: National Academy Press; 1999.
- Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA 2002;288:501-7.