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The recent report from the Institute of Medicine (IOM), "To
Err Is Human," recognizes the domain of anesthesia care as
one of the only disciplines in health care that has taken effective
actions to reduce medical error and improve patient safety. Indeed,
the term "patient safety" was introduced into the medical
lexicon in 1985 as part of the name of the organization several
pioneers established to advance this cause: The Anesthesia Patient
Safety Foundation (APSF). We are elated that the important issue
of medical error and patient safety, a cause that APSF has championed
for more than 15 years, is now receiving the serious national attention
that it needs. Having set an example of success, we offer
our advice and experience on how to create that kind of patient
safety-oriented culture in other segments of the healthcare industry.
The APSF Executive Committee is pleased to share what we believe
to be the reasons for the success of this process. Our model has
been focused, consistent and highly leveraged. That is, we have
accomplished a great deal with relatively few resources by supporting
the efforts of others and choosing a cost-effective dissemination
strategy. It is a model that can and should be implemented by Federal
agencies, by other medical specialties and allied professional groups,
and by health care institutions and systems. It must be said, that
while APSF has led the patient safety process in anesthesia, there
have been many influences, independent and encouraged by our efforts,
that have contributed to what are widely believed to be dramatic
changes for the better. New and better drugs and patient monitoring
technologies, improved training and safer equipment all contributed
greatly to this process. Yet, we believe that trial and acceptance
of these ideas was encouraged by the visibility that APSF brought
to the issue of patient safety. Beyond providing this brief summary
of the APSF experience, we are available to policy makers for further
discussion of this national priority for patient safety.
We have reviewed the recommendations in the IOM report. APSF is
in general agreement with the IOM findings. We agree that medical
error is a serious healthcare concern that must be addressed by
the nation. Indeed, APSF was the first organization to recognize
this, driven by the earliest research into human error in medicine.
Seminal and widely cited studies of critical incidents in anesthesia
identified the previously hidden problem of errors and helped to
prompt the call for action. The concepts embodied in many of the
IOM report recommendations, in fact, follow themes that have guided
efforts of the APSF. However, we believe that some of the IOM recommendations
need serious reconsideration and, in fact, if implemented, could
be counterproductive to the progress made thus far.
We are also concerned that the successes in the evolution of anesthesia
practice as described in the IOM report may be construed to mean
that anesthesia has completely solved all of its safety problems.
While we are very proud of what we have helped to achieve for anesthesia
patient safety, we believe there still remain unsafe practices and
hazards that must be addressed. Indeed, we believe that several
forces, including cost containment and production pressure, are
acting to reverse the progress that has been hard-won during the
last 15 years.
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