nesthesiology was the first medical specialty to champion patient safety as a specific focus. The coincidence of multiple factors beginning in the late 1970s led to significant changes in practice that have decreased mortality and catastrophic morbidity caused by anesthesia administration. The Anesthesia Patient Safety Foundation (APSF) was the first independent multidisciplinary organization (practitioners, equipment and drug manufacturers and many related professionals) created expressly to help avoid preventable adverse clinical outcomes, especially those related to human error. Anesthesiology is widely recognized as the pioneering leader in patient-safety efforts.

Although reports were anecdotal and imperfect, from the 1950s through the 1970s, there was a widespread impression that anesthesia care itself caused a mortality in one to two out of 10,000 anesthetics, which was perceived to be unacceptably high. Anesthesiologists constituted 3 percent of physicians and generated 3 percent of the malpractice claims, but those claims accounted for a disproportionately high 12 percent of medical liability insurance payout.

A seminal publication in 1978 authored by Jeffrey B. Cooper, Ph.D., described the use of the aviation-inspired “critical incident analysis” technique to understand the causes of anesthesia-related mishaps and injuries.¹ In the early 1980s, national media publicity turned a harsh spotlight on anesthesia accidents that injured patients.² An important factor in the anesthesia patient safety movement was the presence of strong leadership from Ellison C. Pierce, Jr., M.D. In 1984 Dr. Pierce, as ASA President, constituted the new ASA standing Committee on Patient Safety and Risk Management, which emphasized the need to address the causes of patient injury. That same year, Dr. Pierce and Harvard colleagues convened the International Symposium on Preventable Anesthesia Mortality and Morbidity, which was the first organized examination of what was soon to be known as “anesthesia patient safety.” It was there that the idea for APSF was born.³

Ellison C. Pierce, Jr., M.D.

‘No Patient Shall Be Harmed’
APSF was launched in late 1985 as an independent (allowing organizational agility and the freedom to tackle openly the sensitive issue of anesthesia accidents) nonprofit corporation with the mission of “assuring that no patient shall be harmed by anesthesia.” Support came from ASA and several corporate sponsors. APSF directors represent a broad spectrum of stakeholders, including anesthesiologists, nurse anesthetists, manufacturers of equipment and drugs, regulators, risk managers, attorneys and engineers.

APSF grew rapidly in impact. Its highly respected quarterly APSF Newsletter has the largest circulation of any anesthesia publication in the world (more than 60,000) and serves to communicate safety-related news, ideas and opinions. The research grant program has funded many projects that provided insight into and suggested solutions for safety problems. The extensive educational efforts included publication of books, co-sponsorship of a large videotape series, organization of the heavily trafficked “patient safety booth” among the exhibits at the ASA Annual Meeting and, more recently, emphasis on the popular APSF Web site <www.apsf.org>.

Technology Advances
In the early 1980s, important advances in technology became available. Electronic monitoring that extended the human senses (inspired oxygen measurement, capnography and pulse oximetry) allowed genuine, real-time, continuous monitoring of O₂ delivery and patient ventilation and oxygenation. In the mid-1980s, medical liability concerns continued, and ASA inaugurated the Closed Claims Study, which continues today as an ongoing project and has yielded important discoveries through study of anesthesia mishaps. Also a committee was formed at Harvard to study the causes of anesthesia accidents there. The analysis led to the first standards of practice for minimum intraoperative monitoring. The intention was to codify and institutionalize specific behaviors that constituted “safety monitoring,” a strategy for preventing anesthesia accidents.

Guidance Through Guidelines
In 1986 ASA adopted an expanded form as a national standard, a landmark step for a medical professional society; this epitomized the lead role taken by anesthesiology in the nascent patient safety movement. Additional ASA standards and guidelines followed, and ASA later developed evidence-based practice parameters, including the widely respected Practice Guidelines for Management of the Difficult Airway.

The American Association of Nurse Anesthetists (AANA) also has promoted patient safety efforts to its members, e.g., through its recent Standards for Office-Based Anesthesia Practice. Again in the 1980s, other engineering advances made anesthesia delivery systems safer, such as gas ratio protection that prevented accidental shut off of oxygen flow. The Food and Drug Administration’s (FDA’s) anesthesia apparatus checkout recommendations were developed and widely adopted. Improvements in anesthesia medications afforded more specific and controllable pharmacological actions and fewer dangerous side effects.

Improving Education
Human factor and resource issues also played a key role in improving anesthesia patient safety. In 1990 APSF and FDA convened an unprecedented expert workshop on human error in anesthesia practice that helped to stimulate later advances. The improved quality both of trainees entering the field and anesthesia training programs are certainly important elements of the anesthesia patient safety story. The extension of the residency to three years and the explosion of anesthesia textbooks, journals and meetings contributed via the knowledge base. The incorporation of sessions on safety topics in the scientific program of the ASA Annual Meeting also raised awareness while disseminating research and information.

In the late 1980s, supported by APSF grant funding, realistic patient simulators were introduced into anesthesiology. Further publicity and advocacy from APSF has led to anesthesiology becoming the leader in the application and adoption of simulators, with strong patient safety implications through education (residents attempting new skills for the first time on a mannequin), training (teamwork, critical event management) and research (human performance). Use of realistic stimulators has now become common in several other specialties.

Due Recognition
The success of the anesthesia patient safety movement was recognized significantly in 1996 when the American Medical Association and corporate partners founded the National Patient Safety Foundation, which was based on the APSF model. Further recognition for safety efforts and leadership came to APSF in the landmark 1999 report To Err Is Human from the Institute of Medicine on errors in medical care.

The 1999 IOM report that praised anesthesiology for its patient safety initiatives.

A “culture of safety” has developed in anesthesia practice, highlighted by the hard work of APSF and ASA as well as by the adoption of a more systems-based approach by many anesthesia departments and groups interested in optimizing outcome of anesthesia care. Overall the combined impact of all the initiatives has been a 10- to 20-fold reduction in mortality and catastrophic morbidity for healthy patients undergoing routine anesthetics, an evolution of which the entire profession can be justifiably proud. By the mid-1990s, liability payouts had decreased to a proportionate percentage, and the insurance “risk relativity rating” for anesthesiology compared to other specialties had been dramatically reduced.

Future Challenges
The work of improving anesthesia patient safety is by no means finished. Equipment and systems still fail at times, and also basic preventable human errors still do sometimes occur. Further, increasing “production pressure” in anesthesia practice from expanding clinical demands in the face of diminishing resources may threaten previously won gains. The profession as a whole must consider and address these challenges.

APSF continues to work diligently both on established tenets and new safety principles. Recent emphasis has been on integrating electronic anesthesia information management systems and audible alarms on physiologic monitors into safety strategies. This stimulated major projects to standardize terminology for anesthesia records and definitions for a proposed widespread anesthesia outcome reporting system, which is being debated. Application of a systems approach to anesthesia care continues though research into the success of “high reliability organizations” and how that model can be applied to anesthesia practice. Most recently APSF has taken the lead in organizing a multidisciplinary conference of experts to consider the effects of anesthesia and surgery on long-term postoperative outcome.

APSF persists in pursuit of its mission of zero tolerance for injury to patients. It serves as a model for the pioneering collaboration and commitment of the entire constellation of anesthesia-related professions to the common goal of patient safety. The success of APSF in the past and the future could not be possible without the vision and financial support of ASA.

References:
1. Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: A study of human factors. Anesthesiology. 1978; 49:399-406.
2. Tomlin J. The deep sleep: 6,000 will die or suffer brain damage. WLS-TV Chicago, 20/20. April 22,1982.
3. Pierce EC. The 34th Rovenstine Lecture: 40 years behind the mask: Safety revisited. Anesthesiology. 1996; 84:965-975.

Robert K. Stoelting, M.D., is President of the Anesthesia Patient Safety Foundation.

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