FDA Issues Pre-Use Checkout
Grants to Be Awarded
Patient Safety at the ASA
Current Questions in Patient Safety
Anesthesia Machine Key Component of Safety
U. Penn Organizes to Maximize Safety
From the Literature
by Peter Carstensen
Most anesthesia deaths and injuries attributable to pre-existing equipment faults or to errors in equipment set-up could be avoided if the function of anesthesia apparatus is adequately checked before each case. Although these set-up errors and faults do not account for the largest portion of anesthesia untoward incidents, they are a source of patient risk which clearly can be addressed.
Manufacturers do provide checkout instructions in their operator's manuals. Variations of suggested checkout procedures are available in the literature.
Yet, there is evidence that some anesthetists still do not fully conduct a proper pre-use check of their apparatus. Further, there may be anesthetists who are not convinced of the need to routinely conduct a complete check of the equipment before use.
Two years ago the FDA met with representatives of the anesthesia medical community and industry to discuss cooperative efforts to reduce patient risk during anesthesia. During that meeting the agency was asked to take the lead in developing and issuing a general guideline for users on how to perform a pre-use checkout on anesthesia equipment. The objectives of such FDA-sponsored guidance were to promote the concept of routine checkout and to provide basic techniques that anesthetists could adapt to their own specific equipment and clinical practices.
The general guideline, "Anesthesia Apparatus Checkout Recommendations;' was developed by a small group of experts which included practicing anesthesiologists, biomedical engineers, and industry representatives. This initial draft was based on a checklist developed over ten years in the residency program at Massachusetts General Hospital. This was modified and honed substantially over an 18-month period. Elements of checklists from other recognized sources were incorporated. The resulting procedure was evaluated at several hospitals and by the three major manufacturers of anesthesia machines. It was then reviewed by FDA's advisory panel on anesthesiology and respiratory therapy devices. A Notice of Availability of the draft checkout recommendations was published in the March 28, 1986 Federal Register to solicit public comment.
The final version of the checkout recommendations, which appears in this issue of the APSF Newsletter, provides a general checkout and inspection procedure designed to be performed daily and, in an abbreviated form, before each case by anesthesia professionals. It is designed to ensure that the anesthesia gas machine, patient breathing system, monitors, and other apparatus which together comprise the anesthesia delivery system are correctly interconnected, are properly adjusted, and function as expected. Although the checkout recommendation is being issued by the FE)A, it is not a federal regulation and clinicians are not legally obligated to use it. It is only intended to be used as a guideline which anesthetists should modify as needed to accommodate differences in equipment and variations in local clinical practice. Modifications are not only appropriate but they are encouraged. It is suggested that such changes be peer reviewed.
One example of an appropriate modification to the checkout recommendation which users may wish to make relates to the test for leaks in the machine and breathing system presented in step 16. This generic leak test, although appropriate for all machines, requires some care to perform correctly on machines which employ check valves upstream of the common gas manifold. If not performed precisely as dm3iW, a significant leak may go undetected. To avoid this problem, one manufacturer of such machines provides special test apparatus and a different method for accomplishing this leak test. This manufacturer would prefer that the users test the machine as described in the operator's manual. This illustrates the need to carefully review the operator's manual before using the checkout recommendations. The FDA recommendations do not relieve users of their responsibility to be aware of any special procedures or precautions described in the operator's manual supplied with their equipment.
Early in the development process, it was resolved that the recommendations should be kept as brief and as simple as possible to be practical for daily clinical use hence the single page format. Yet, it needed to be generic and sufficiently comprehensive to detect most of the common setup errors and equipment defects. These competing objectives complicated the development and led to compromises. For example, one trade-off centered around a means to detect a grossly malfunctioning vaporizer. While the test considered was useful and desirable in principle, it was judged too complex and time consuming to justify including it given the rarity of such a gross malfunction. Some users may disagree with that decision and may wish to include such a test in their own daily routine. For information on one way to perform such a test, contact: ECRI (5200 Butler Pike, Plymouth Meeting, PA 19462).
The checkout procedure should be adequate explanation for most users, however, a more detailed description of most of the tests can be found in the companion publication to the educational videotape "Machine Check-Out" in the ASA Patient Safety Series. That checkout procedure is similar to the FDA recommendations. Copies may be obtained from the ASA. An additional source of detailed information on pre-use of anesthesia apparatus is Understanding Anesthesia Equipment, (2nd Ed.) by Dorsch and Dorsch (Williams & Wilkins, 1984).
The ASA, AANA, and industry plan to assist the FDA in disseminating these checkout recommendations. It is anticipated that copies will be made available by anesthesia equipment manufacturers and that the recommendations will be reprinted in ASA and AANA publications. A Notice of Availability is also scheduled to be published in the Federal Register informing the public of the availability of the final "Anesthesia Apparatus Checkout Recommendations." Additional copies of the checkout recommendations may be obtained on request by writing to the Division of Technical Development (HFZ-240), Office of Training and Assistance, CDRHIFDA, 5600 Fishers Lane, Rockville, MD 20857.
Mr. Carstensen is Engineering Consultant, Center for Devices
and Radiologic Health, U.S. Food and Drug Administration.
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Twenty-six applications for research grant funds have
been received by the APSE The APSF Committee on Scientific Evaluation is
studying the applications and will soon announce awards for grants up to
$35,000 for projects to begin January 1, 1987.
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Several presentations at the October 17-21 annual meeting of the American Society of Anesthesiologists will be related to anesthesia patient safety. There will also be the Patient Safety Booth display sponsored by the ASA Committee on Patient Safety and Risk Management among the exhibits.
"Lessons learned from malpractice review" will be covered in a Refresher Course lecture by Ronald Katz, M.D. on October 17.
"Deciding on gas monitoring" is the topic of a workshop organized by Nikolaus Gravenstein, M.D. October 19.
"Anesthetic standards and risk management" is the subject of a panel organized by Ellison Pierce, M.D. for October 20. Discussants will be John Eichhorn, M.D.; David Swedlow, M.D.; Attorney Edward Brennan; Burton Epstein, M.D.; and St. Paul Insurance Medical Services Manager Mark Wood.
Finally, "Safety issues in pediatric anesthesia" will be presented in a workshop directed by Anne Lynn, M.D. also on October 20.
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Question: The hospital administration at our large teaching institution has proposed that all incoming residents be subjected to urinary drug screening tests. What are these, are they legal, and will they help increase patient safety?
Answer: Urinary drug screening is a very contemporary and "hot" issue involving many disciplines ethics, medicine, labor relations, economics and law. Above and beyond alcohol, it is estimated that 5 13% of the American workforce are substance abusers. These figures are paralleled by studies of the medical profession. While constituting only 3.6% of all U.S. physicians, anesthesiologists represent 10 13% of all physicians in drug treatment programs. Recent data ominously suggest that a large number of physicians treated in rehabilitation programs had a long history of drug use, often predating their entry into medicine. Some of the "flower children" of the 60's have become physicians of the 80's.
On his most recent hospitalization, President Reagan voluntarily underwent urinary screening to give impetus to the recommendation of his Commission on Organized Crime calling for mandatory testing of all federal employees with security clearances or safety related occupations. Preemployment screening of job applicants for drug use is the most prevalent form of drug testing now in use. It is estimated that more than 30% of all Fortune 500 companies have some sort of drug testing program.
The public generally reacts with ambivalence to drug screening. On the one hand is concern about an Orwellian society with Big Brother overlooking every action. On the other hand, when public saw is involved, opinion strongly supports screening for occupations such as airline pilots, locomotive engineer, public safety officer, air traffic controller, and presumably even physician.
The American Board of Anesthesiology and the American Society of Anesthesiologists both acknowledge the growing problem of substance abuse in recent publications. In the 1986 ABA Booklet of Information the Board has a new policy on chemical dependency (Section 6. 1) and the ASA has recently issued a pamphlet entitled "Questions and Answers About Chemical Dependence and Physician Impairment," which all anesthesiologists should read. Neither publication, however, addresses the issue of drug screening.
Basically, drug screening pits the employee's right to privacy against the employer's attempt to assure quality, avoid liability, and reduce costs. In cases where public safety is involved (including anesthesia) society has an interest in seeing that lives am not in the hands of someone whose judgment is impaired by chemical dependency. Advocates of urinary screening cite successes. Law firms instituting such policies report marked reductions in work-related illness and injury (substance abusers are three times more likely to injure themselves or an innocent third party), absenteeism, and fringe benefit costs (notably health insurance). From an industrial risk management point of view, it is a very cost effective policy.
Opponents argue, however, that urinary drug screening is coercive, is contrary to the tradition of innocent until proven guilty, and violates due process protections when done without just cause. In opposing government-mandated testing, they cite the Fourth Amendment on illegal search and seizure and the Fifth Amendment prohibiting self incrimination. Yet, such arguments do not apply to private employers such as hospitals. Opponents claim the technology is often flawed and subject to false positives and even false negatives. Fentanyl, a drug often chosen by chemically dependent anesthesiologists, cannot be detected by the common urinary screens.
The two most widely used methods of urinary screening are the EMIT system distributed by Syva Co. and the ABUSCREEN System from Roche Diagnostics. Initial claims of 97 99% accuracy have not been supported and confirmatory gas chromatography mass spectrometry (GCMS) is necessary when screens yield positive results. GCMS is 100% accurate for marijuana, cocaine, amphetamines, barbiturates, benzodiazepines, opiates, PCP, methaqualone and methadone, but at considerably greater cost. In all cases, to avoid liability from false incrimination and to maintain legal validity, the screening procedure requires an airtight "chain of evidence custody." It must be remembered too, that drug testing is only one part of a total approach to reducing chemical dependency and substance abuse in the workplace and does not even address the more prevalent problem of alcoholism. It is an inescapable reality that all hospitals should have a Committee on Physician Health (or some similar title) that deals with detection, treatment and most importantly, prevention.
In summary, urinary drug screening be legal and is winning greater public acceptance especially when administered in a fair, impartial and accurate manner. Screening must be followed by more accurate confirmatory tests before any denial of employment. One major teaching institution in New York City already requires pre-employment urinary screening of all employees including residents; San Francisco, however, has a recently passed ordinance prohibiting random screening without cause. While the legal and ethical issues have not been fully resolved yet, drug abuse screening may serve to protect and, more importantly, reassure the public. At the same time, it will identify colleagues in need of rehabilitation and support before it is too late.
Answer by David E. Leo, M.D., Professor and Chairman, Department of Anesthesia, New York Medical College and Chief, Westchester County Medical Center.
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by Anne Berssenbrugge Ph.D. and Kay Plantes, Ph.D. (Part one of two parts)
Electronic monitoring of patient status as a key element of anesthesia patient safety is well recognized in discussions on standards of anesthesia cam Perhaps less recognized, however, is the contribution of anesthesia machine design in promoting anesthesia safety and the importance of assessing the adequacy of old equipment which may lack the safety features inherent in current technology.
During the past 75 years, the anesthesia delivery system has undergone near-total technological change, with its primary advancements directed toward prevention of anesthesia mishaps. The anesthesia machine has evolved from a simple mechanical gas delivery device to a sophisticated system designed to still deliver gas but also minimize anesthesia risk and enhance human vigilance. Some of the more significant safety features which have been incorporated into the design of the anesthesia system include
1. Safety mechanisms which help to ensure the presence of at least a nominal 25 percent oxygen in oxygen/nitrous oxide gas mixtures, thus preventing delivery of a hypoxic mixture
2. A standing-bellows-type ventilator (i.e., the bellows rises, rather than falls, during each patient exhalation) which will not cycle if an accidental disconnection occurs within the patient circuit. Thus, monitoring the bellows can provide an immediate indication of a breathing system problem.
3. An integral vaporizer interlock designed to prevent the simultaneous operation of more than one vaporizer, thus reducing the potential for accidental administration of multiple anesthetic agents at the same time.
4. Ventilator low pressure alarms which help protect the patient from the danger of circuit disconnection or simple hypoventilation; and ventilator high pressure alarms and automatic pressure relief valves which help protect the patient against excessive airway pressure.
5. Latching and bayonet-type connections on gas hoses and pressure sensing tubes which help prevent accidental disconnection.
6. Size-dissimilar fittings and varied hose sizes which help ensure correct connection of gas, scavenging, and breathing system connections.
7. Isolation of vaporizers and special vaporizer manifolds that allow fresh gas to flow through only the vaporizer in use, minimizing the potential for contamination of effluent gas with another volatile agent.
8. An integrated bas-to-ventilator switch valve
which removes the automatic pressure limiting ("pop-off") valve from the patient circuit during ventilator operation, rather than relying on the user to remember to close the valve when switching from manual to mechanical ventilation.
to minimize the number of exposed hoses, and thus the chance for accidental disconnection.
Perhaps the most important safety improvement in current anesthesia machines is the integration of monitors into the anesthesia system, to provide added vigilance over both the machine and the patient. For example, circuit oxygen concentration and exhaled patient volume monitors may provide early warning of hypoxic mixtures, circuit leaks, or accidental disconnections. Integration of these and other monitors (e-g., capnography, pulse oximetry, noninvasive blood pressure, etc.) into the anesthesia system helps to ensure that monitors are on and functioning prior to activation of gas delivery and improves the management of the multiple machine and patient connections.
The integration of electronic monitors into advanced anesthesia systems and the adoption of the safety devices outlined above has occurred primarily during the past decade; many crucial safety devices have been developed within only the past five years. Thus, while current advanced anesthesia systems incorporate these safety features as standard components, many anesthesia machines ,which remain in use today lack the majority, if not all of them.
The problem is age. One market survey showed that approximately one-third of all anesthesia machines in U.S. hospitals are more than ten years old and, therefore were manufactured prior to the development of the newer safety technology. Barring extensive upgrading, which is often not feasible due to the initial design of older units, they may lack crucial safety features.
Many hospitals have acted in recent years to remove older anesthesia machines from service at a faster rate than occurred in the past in favor of newer equipment with enhanced safety and performance features. However, it is clear that there are still many units in use which do not have these guards against anesthesia mishaps. Replacement of this old anesthesia equipment would seem to be an essential part of any plan to improve anesthesia patient safety.
Discussions of anesthesia safety and standards of anesthesia care should include this important issue as all involved strive to improve patient cam
Anne Berssenbrugge Ph.D. is Product Manager and Kay Plantes, Ph.D. is North American Marketing Manager, Anesthesia Systems, Ohrneda, Madison, WI.
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Australian Anesthesia Deaths Changing
by Dr. Ross Holland , Director of Anesthetics and Resuscitation,The Parramatta Hospitals Westmead, New South Wales, Australia
A striking difference has emerged in the profile of anesthesia techniques represented in cases reported to the NSW Mortality Committee during the 3 years from July 1, 1983, compared with the 20 years from 1960 1980.
Regional anesthesia, which was represented at a low level in the earlier years of this study, has increased markedly and now is used in over 20% of anesthesia-attributable mortality.
Likewise disproportionate representation of hip surgery appears in recent times. The death figures are as follows
|Total anesthesia attributable deaths||575||51|
|Regional Anesthesia deaths and % of total||32 (5.6%)||12 (25%)|
|Hip Surgery deaths and % of total||29 (5%)||16 (32%)|
|Regional Anesthesia for hip surgery and % of hip deaths||3 (10%)||9 (56%)|
The Victorian Consultative Council on Mortality and Morbidity in anesthesia has published its second report, generating some controversy over certain statements made by the Council.
For instance, spontaneous ventilation techniques have been criticised, and an arbitrary time limit of one hour recommended. It has also suggested that post-operative fever should be regarded as a contra-indication to the use of halothane, unless another obvious explanation for the fever exists.
On the other hand, interesting facts appear in the report. Of the 10 well-documented cases of anaphylactic/oid reactions, nine survived, and all but one are in their pre-existing state of health.
This study is wholly voluntary, both in notification and description of incidents. As such, of course, it is subject to considerable bias, but useful material does continue to be reported, and the Council's publications appear promptly and at reasonable frequency.
In Melbourne in July, a symposium on anesthesia mishap was held. More complete reporting of this meeting will appear in a future issue, but a legal opinion given at the time has caused considerable concern. Briefly, it was to the effect that if a patient dies under anesthesia for any Mason, and a monitor which was available in the Operating Suite, has not been used, the anesthetist is indefensible in any subsequent action.
Clinicians expressed outrage at this simplistic approach, but were assured that however unscientific it may appear to them, courts, and particularly juries, see the matter differently.
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By Stanley J. Aukburg, M.D.
The University of Pennsylvania Department of Anesthesia has adopted a multifaceted approach to the management of anesthetic risk. Our goal is to provide the safest possible environment for anesthesia and surgery in an affordable manner. The realities of the malpractice liability environment forced the inclusion of liability costs in our cost-benefit ratio analyses, because our Department has multi-layered malpractice liability coverage with a substantial self-insurance component. Our approach is based on information available in the literature supplemented by reports provided by three in-house committees.
1. The Department is represented at the Medical Board's Medical-Legal Committee and the Clinical Practices Malpractice Underwriting Committee. Pertinent information (type of case, problems posed, weakness in defense, errors made, etc.) are presented at periodic intervals to the attending and resident staff. The cases discussed are not just anesthesia-related, but include any and all cases where there is a point to be made in the area of risk management. How these cases might apply to our practice is also explored.
2. There is an ongoing Quality Control Program, wherein certain aspects of our practice are scrutinized to discover compliance with and effectiveness of regulations. Areas that need improvement are reported. The reports are presented to the Anesthesia Staff on a monthly basis. This Quality Control Program is complemented by another Department committee which reviews all operative deaths on a monthly basis. A formal report is made on all deaths that occur within the first 48 hours of surgery, or regardless of the time if anesthesia is deemed to be implicated in the demise of the patient.
3. There is an Incident Report System for anesthesia currently in place which requires the reporting of a number of potential and actual problems. These include, but are not limited to, 1. drug administration errors, 2. blood administration errors, 3. myocardial infarction within the first two post-operative hours, 4. cardiac arrest in the OR or RR, 5. dental complications, 6. bums or pressure sores, 7. cancellation of surgery after the patient has arrived in the OR, 8. iatrogenic patient injury, and 9. at the physicians' discretion. These reports are submitted to the Department chairman and are handled as Department business or passed on to a joint committee of the Medical Board and the Clinical Practices Executive Committee if the problem is more involved.
Benefits that have accrued from these reporting mechanisms include improved awareness by all staff and improved charting and record keeping. The end result should be better patient care. The information gained from the-se sources, in addition to helping establish priorities, proved very useful in demonstrating to the administration the need to provide improved monitoring and anesthesia delivery equipment in the OR's.
The most serious mishaps so far reported invariably include a period of hypoxia in their etiology. These were frequently related to accidental hypoventilation. We found that anesthesia mishaps and "near misses" were no more likely to occur during major surgery than during minor "noninvasive" procedures. Similarly, they were no less likely to occur in ASA Class I patients than in sicker patients. Furthermore, patients receiving regional anesthesia with sedation were at as high a risk as those receiving general anesthetics. It was dear that our existing procedures including routine continuous use of a precordial stethoscope and continuous monitoring Of F]02 were not sufficient to ensure lowest possible risk. Therefore, devices designed to reduce the likelihood of hypoxic incidents were sought for all anesthetizing locations.
Non-invasive monitors of respiratory function were first introduced to our institution in 1978 when it was decided to include infra-red C02 analyzers with continuous wave form display in all physiologic monitor purchases for the operating room. In 1979, we began to specify airway pressure disconnect and overpressure alarm in all anesthesia machines purchased. In 1983, 02 analyzers switched by an anesthesia machine main switch were added to our specifications. Finally, in 1985, pulse oximeters were purchased for every anesthetizing location.
Installation of all equipment was completed early this year. Staff and residents find the equipment easy to use. Many situations in which unsuspected ventilatory insufficiency or significant arterial desaturation occurred were revealed by the monitors before clinical signs developed. They have been reported to our internal screening groups. Examination of statistics looking for reduction in the incidence of actual complications will take place at intervals in the future.
Organization of alarm presentation and prevention of distracting false positive alarms have been set as our next priority.
Dr. Aukburg is Associate Professor of Anesthesia, University
of Pennsylvania, and a member of the APSF Newsletter Editorial Board.
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Editor's note: In each APSFA newsletter, a pertinent publication from the anesthesia patient safety literature will be summarized. Suggestions for future issues are welcome.
Cohen, M.M., Duncan, P.G., Pope, W.D.B., and Wolkenstein, C: A survey of 112,000 anesthetics at one teaching hospital (1975-83). Can Anaesth Soc 1, 33: 22-31, 1986.
For nine years, the Department of Anesthesia at the University of Manitoba in Winnipeg methodically collected data on the intraoperative, recovery room, and post-operative complications experienced in 112,000 anesthetics. This large teaching hospital with a high proportion of ASA I or 2 patients (79% during the last 5 years of the study) had almost the full spectrum of procedures, weighted toward perineal (26%) and intraabdominal (23%). There was no obstetrics and open hearts were done during the last three years only. Data on patient pre-operative conditions, intraoperative monitoring, and anesthetic techniques are presented, divided into two time periods to suggest evolving practice patterns in recent years: sicker patients, more monitoring, more narcotic agents, and more local anesthesia.
This is probably the most comprehensive report ever published about the distribution of anesthesia complications in a large, well defined sample of patients. The study methodology is credible. Cooperation from the anesthetists was exceptionally good (about 2% of cases not documented) perhaps because the data collection was incorporated with the billing procedure Most striking is that, during the period 1979-83, fully 10.6% of patients had at least one intraopertive complication; 5.9% had a recovery room complication; 9.4% had a "minor" post-operative complication, and 0.45% had a "major" post-operative complication.
Overall, 17.8% of patients had at least one anesthetic complication.
The most frequent types of problems were. intraoperative arrhythmias and hypotension (7.8/10,000 cardiac arrests and 6.3/10,000 aspirations); recovery room hypotension and hypertension; post-operative nausea and vomiting (about 5%). The reported rate of post-op MI was 13.7/110,000.
The study (and the basic methodology) has some weaknesses. Self-reported data are always questionable. There is no information about causality. No information is given in this report about possible differences in the rates of complications among anesthetists (the relevance of such comparisons emphasized by the recent report from Slogoff, et al on post-operative MI rates).
It is certainly impossible to compare this database to others as there are no standard definitions; there is no objective way to normalize for differences in patient acuity or classification or complexity of surgery. Still, presented here is a detailed baseline distribution of anesthesia-related complications. There are comparisons of patient acuity, anesthetic techniques, and monitoring during two time periods and, thus, this study offers some objective measure on how anesthesia practices are changing. Illustrated is a reasonable way for any group of anesthesia personnel to track its performance
It is often suggested that the risk of death or serious injury from anesthesia is relatively low, yet still intolerably high. But, the fact that so many patients experience some form of anesthetic complication (in what is widely regarded as an anesthesia department of the highest quality) supports the suggestion that anesthesia is serious business. Because mortality rates are so low, they are almost impossible to use as a yardstick for assessing how differences in technique or practices impact outcome. Using a broader definition of adverse outcome, such as the complications described in this report, may be a more useful measure of anesthesia "quality" or performance. Additional reports similar to this one by Cohen, et al, should be encouraged. It is only from many of these, all of which can be justified as valid quality assurance activities, that meaningful comparisons can be made. These investigators and their open-minded clinical colleagues should he thanked for leading the way.
Abstracted by Jeffrey B. Cooper, Ph.D., Harvard Medical School.
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"SITTENDRIP," an illustration by Leonard W Hill, M.D.
that appeared in the November, 1954 ASA Newsletter revealing his impression
of "an anesthesia control booth of the not too distant future, when electronic
gagetry has reached fuller flower." It is often sad that remarkable vision
into the future can only be truly appreciated in retrospect. Note the cardiotachometer,
automatic blood pressure cuff, infusion pumps, and recording spirometer.
A forerunner of a pulse oximeter is at the middle right and just below
that possibly an early capnograph. Ed. (Furnished by Mr. Patrick Sim of
the Wood Library-Museum of Anesthesiology).
The Anesthesia Patient Safety Foundation Newsletter is the official publication of the nonprofit Anesthesia Patient Safety Foundation and is published quarterly in March, June, September, and December at Overland Park, Kansas. Annual membership: Individual $25.00, Corporate 500.00. This and any additional contributions to the Foundation are tax deductible
The opinions expressed in this newsletter are not necessarily those of the Anesthesia Patient Safety Foundation or its members or board of directors.
APSF Executive Committee: Ellison C. Pierce, Jr., M.D., President; W. Dekle Rountree, Jr., Vice-President; E.S. Siker, M.D., Secretary; Burton A. Dole, Jr., Treasurer; Jeffrey B. Cooper, Ph.D.; Joachim S. Gravenstein, M.D.; James F. Holzer, J.D.
Newsletter Editorial Board:
John H. Eichhorm, M.D., Stanley 1. Aukburg, M.D., Ralph A. Epstein, M.D., David E. Lees, M.D., E.S. Siker, M.D., Mr. Mark D. Wood
Address general correspondence to: Administrator
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Park Ridge, IL 60068
Address Newsletter comments, questions, letters, and suggestions to:
John H. Eichhorn, M.D. Editor, APSF Newsletter Anesthesia,
DA-717 Beth Israel Hospital Boston, MA 02215
0 Please send the ASA Patient Safety Videotape Series
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