Support and Service Crucial to Safety
CT Area Hospitals Set and Meet Strict Monitoring Standards
Letters to the Editor
From the Literature: Views of Minimal Monitoring
Monitoring Journal Stresses Safety Equipment
Anesthesia Safety Workshop Also Considers Cost of Efforts
Current Questions in Patient Safety: Quality Assurance
N. Carolina Organizes for Patient Safety
System Needed for Equipment and Monitors
by Wesley T. Frazier, M.D.
There now seems to be agreement that safer anesthetic care is facilitated by: 1) a better trained and better coordinated anesthesia care team through better recruiting and improved4onger training; and 2) more complete monitoring of the patient and the anesthesia delivery system.
An area lacking general agreement (eg., due to differing philosophies, lack of data, etc.) is what kind of Support/Service System is needed to facilitate item #2 - the support of monitors (both patient and delivery system) and the anesthesia delivery system itself.
Support/Service Systems are broadly defined (for the purpose of this discussion) as: procedures/ personnel/space/budget to facilitate the acquisition, utilization, and service of the monitors (patient and delivery system) and the anesthesa delivery system. Service per se is defined as set-up, calibration, testing, troubleshooting, and repair of anesthesia equipment (monitors and delivery system). There are several other areas interdependent with the issues of support/service, but which are beyond the scope of this article (e.g., education of users in the operation and interpretation of monitors, research and development, and feedback from the field to the manufacturers).
The relationship between equipment performance (failure, ease of use, etc.) has been considered by Westenskow and Cooper "2 in their introductory articles in a special symposium in Medical Instrumentation ("Symposium on Safety in Anesthesia"). Issues of Clinical Engineering support and the roles of anesthesia department support personnel were also addressed in this symposium 3,4 Cooper states that "equipment failure rarely contributes to anesthesia related injuries (less than 5% of all deaths)". Yet, these incidents do exist and the public, legal, and regulatory communities expect us to reduce this " 5%" incidence to near zero. Furthermore, just as there are no hard numbers to document the role of better monitoring/delivery systems in assuring safer anesthesia care, there are no hard numbers to delineate the role of anesthesia Support/Service Systems in assuring better function of monitoring/delivery systems. Preliminary data indicate that technical assistants do seem to make a contribution to monitoring and delivery systems, but studies in many clinical settings are needed to document what such assistants do nationwide. (4)
It is unlikely that any study will be designed to prospectively test & efficacy of anesthesia Support/ Service programs (i.e., no institution would volunteer to be the control group). We, therefore must rely on common sense and anecdotal data (i.e.-, cases of monitor and/or delivery system failure) to guide us in a national program to improve and standardize our Support/Service programs. How extensive should these programs be and where will we get the budget and personnel to support them?
In terms of in-house personnel, anesthetists who have special experience in this area often help with managerial functions, but it is likely that specially trained workers will be needed, especially in many of the larger departments. It is known that many departments already have significant efforts to train in-house personnel to assist with Support/Service functions and in the near future a survey of the characteristics of such personnel should be available. 5 In California, a group has been organized on a state-wide basis to assist with coordination and communication in this area.
The personnel available to anesthesia departments to manage and carry our specific Support/ Service programs can be categorized in the following ways:
1. Anesthesiologists and anesthetists with special interest and training in equipment design, function, and service;
2. In-house (departmental) specialist ("Anesthesia Monitoring and Equipment Specialist") who perform various functions which range from setting up monitors to much more complex tasks including some checks and minor repairs of anesthesia machines; (4)
3. In-house specialists (usually with a background in Biomedical Engineering Technology i.e.-, BMET'S) who perform major repairs and who work out of the central Biomedical Engineering Department or may be in an advanced support group directly attached to the anesthesia department; (3)
4. Contract Specialists i.e., service representatives of the manufacturers and/or independent service companies.
Given the considerable implications of support of the functions of monitors and critical life support systems (i.e., anesthesia machines), there are serious questions concerning the recruiting, training, and qualifications of personnel in the categories 2, 3, and 4 above. It is likely that individuals in category 2 are largely trained on the job, although some are likely to have backgrounds in Respiratory Therapy, Biomedical Engineering, and other related fields. 5 Although progress has been made in making the needs of anesthesia known to the BMET and clinical engineering groups (at national biomedical engineering meetings, largely through the efforts of Cooper, Welch, Newbower, and Philip of the Harvard group), it is doubtful that this is yet reflected in training programs and certification exams. In regard to category 4 (i.e., factory and "third party" service representatives), they are, in many instances, likely to be well trained, but there is no assurance that this is so, especially if "third party" service representatives have not been to a "factory" authorized school. Also, there is no assurance that factory authorized service representatives are trained to standards which the larger anesthesia community would support.
In consideration of Support/Service Systems for anesthesia departments, the issues of procedures/ space/personnel/budget are interdependent, but the most fundamental is personnel. It is unlikely that enough are available who have the right training. Once we have decided on the tasks which need to be performed (a major undertaking), we can recruit/train/examine the personnel to carry out these procedures. This takes a great deal of planning, effort, and time. Once we know what kind of support personnel we need (and how many such personnel), we can negotiate for space and budget.
Nevertheless, discussions as to what kinds of monitors and delivery systems are going to be utilized are common and purchases are proceeding at a very rapid pace independent of preplanning as to what kind of support/service program is needed. Due to this lack of a pre-existing Support/ Service System, anesthesia may he on a collision course for unfortunate incidents. There is already a serious question as to whether or not we are supporting even the machine-s/monitors that we now have. There is an even greater question as to whether we will be able to plan and implement a service program in time to adequately meet the needs of the next decade.
By analogy to the automobile industry, it is as though the manufacturers and their consuming public had decided to take a 1940 car and add to it an automatic transmission, air conditioning, disc brakes, turbo-charging, fuel injection, trip computers, and stero without retraining the mechanics (to say nothing of the drivers), and without enlarging the service departments. Even before we have support systems in place to deal with yesterday's needs, the new day is upon us OR's abound with pulse oximeters, capnometers, mass spectrometers, new indirect blood pressure monitors, EEG analyzers, etc. and new (partially electronic) anesthesia machines are here or just around the comer.
What do we do now? The following outline and brief discussion offers some suggested actions:
1) Evolve a plan of action on a departmental basis
a. Assess current programs and new needs;
b. Draw up a stepwise plan (timetable) to make improvements;
c. Assign specific responsibility to designated persons;
d. Negotiate with hospital for space and personnel (budget) to establish or enlarge efforts;
e. Document methods of periodic assessment of proper operation and results of the overall plan.
2) Review departmental Support/Service program to assure availability of
a. Job descriptions of (assisting) personnel;
b. An inventory of equipment (including labeling);
c. Procedures for set-up, calibration, testing, troubleshooting, and repair;
d. Policy for division of responsibility between in-house personnel and outside contractors (e.g., factory service personnel);
e. Documentation of manufacturer's recommendations for service;
f. Operational manuals.
3) Support national efforts to establish guidelines for different types and sizes of hospitals:
a. Types of in-house Suppor/Service personnel needed;
b. The type and amount of Support/Service expected from contract organizations (e.g., factory service personnel or "third" party service companies);
Dr. Frazier is Associate Professor of Anesthesiology and Director, Division of Instrumentation and Monitoring, Emory University School of Medicine.
1. Westenkow DR and Cooper IB (1985). "Safety in Anesthesia: The Role of Engineering". MEDICAL INSTRUMENTATION, 19 (3): 104.
2. Cooper IB (I 985). "Anesthesia Can Be Safer: The Role of Engineering and Technology". MEDICAL INSTRUMENTATION, 19 (3): tO5-108.
3. Welch JP (1985). "Clinical Engineering in Anesthesia". MEDICAL INSTRUMENTATION, 19 (3); 109-112.
4. Frazier WT, Kelly PIT-and Lewis JE (1985). "The Anesthesia Instrumentation and Monitoring Specialist". MEDICAL INSTRUMENTATION, 19 (3): 113t IS.
5. McMahon. D and Thompson G (1987). "A Survey of Anesthesia
Support Personnel in Teaching Departments". (Virginia Mason Clinic, Seattle,
Washington. in preparation.)
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by Ralph A. Epstein, M.D.
In the December, 1986 issue of the APSF Newsletter, we reported that in November, 1985, the chiefs of anesthesiology of the 13 hospitals in the Hartford, Connecticut region met and agreed to a policy statement promulgating as a standard of care the use of pulse oximetry for all anesthetized patients and recovery room patients and, also, the use of capno8raphy during general anesthesia. At that time, only a minority of the hospitals in the region were making significant use of these monitoring modalities. The anesthesiology chiefs believed that a uniform and public policy would help them acquire the equipment they thought was needed.
To determine the magnitude of the improvement in safety monitoring ability in the year following the meeting, a survey was done of the 1 3 hospitals. The chiefs furnished information concerning the number of anesthetics per year in their institutions and the frequency of use of pulse oximeters during regional and general anesthesia, as well as in the recovery room, and the frequency of capnography during general anesthesia during the month of January, 1987. To determine the frequency for the entire region, the individual hospital rates were weighted by the number of anesthetics in that hospital.
The survey covered a total of 78,900 anesthetics per year. The frequency of use of pulse oximeters was 76% during general anesthesia, 71% for regional anesthesia, and I 8% during the recovery room period respectively. The frequency of use of capnography during general anesthesia was 60%.
The chiefs were also asked to predict what the frequency of such monitoring would he in their institutions in January, 1988. The rates for the
greater Hartford area were estimated under the assumption of no change in individual hospital case loads. The predicted frequency of the use of pulse oximeters next year is 97%, 87%, and 43% during general anesthesia, regional anesthesia, and the recovery room respectively. The predicted frequency for the use of capnography during general anesthesia is 86%.
We conclude that non-invasive monitoring of oxygenation and the adequacy of ventilation has become the standard of practice in the Hartford, Connecticut region. It appears that it is practical for this type of change in practice standards to occur in as little as two years when there is a consensus among the involved chiefs of anesthesia departments.
Dr. Epstein is Professor and Chairman, Department of Anesthesiology
University of Connecticut Health Center and a member of the APSF Newsletter
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Fatigue Cited as 'Enemy' of Safety
To the Editor:
In the supplement of the December, 1986 Newsletter reference is made to the airline industry. This is in regard to technological advances in safety.
I would like to draw attention to this industry also, but from a different viewpoint. The airline pilots to whom we are often compared, are light years ahead of our specialty in one particular aspect, i.e., the limitations on their hours of work. As a result the public appreciates that at the controls there will always be a Captain who is not fatigued.
In the same vein our patients, plus the insurance industry, would I'm sure, be very appreciative if the same could be said of anesthesiologists.
I have no idea of the part played by fatigue in anesthetic accidents, but it must be considerable. As a practicing anesthesiologist for 36 years, I am only too aware of the near misses when one has been sleepless. It is customary, where I practice, to live in the hospital for 24 hours when on call. Frequently sleep is impossible and equally frequently our most critical cases come in well after midnight.
This is a situation and circumstance that must be changed. No anesthesiologist should be permitted to work a 24 hour shift. Would any of us like to be subjected to the ministrations of a sleepless colleague? Obviously if hours of work are restricted, fee schedules will have to be adjusted accordingly.
I consider fatigue to be Enemy No. I in our efforts to increase the safety of anesthesia. Its elimination might obviate the cacophonous orgasm of flashing lights and warning buzzers heralding yet another anesthetic disaster.
Patrick M.E McGarry, M.B. F.R..C.P. (C) Winnipeg, Manitoba
Machine Maintenance Stressed
To the Editor:
Dr. Meyers (APSF Newsletter, Dec. 1986) is rightly concerned about standards for in-house technician maintenance when an inspection sticker is applied to an anesthesia gas machine.
Maintenance of modem gas machines now embraces multiple technologies including mechanical, electronic and computer applications for which technicians are seldom adequately prepared. Moreover, with the current proliferation and complexity of hospital equipment, the technicians may also be time-limited and be able to conduct only the most perfunctory tests. Thus their primary standard is often that of 'passing the ICAH inspection'.
For better quality control, I suggest that we pay more attention to the capability for good maintenance. Manufacturers must provide more self-test and diagnostic facilities in their equipment, and more informative teaching material designed specifically for operator and technician training. For their part, hospitals must train their technicians to be knowledgeable in all the technologies involved, and must optimize their maintenance procedures whereby the maintenance and performance verification can be carried out fast and effectively. In some cases, it could be appropriate that an anesthesiology department determine which technicians are assigned to the work, what they know, and what they do.
Michael Shaffer, D.Sc. Professor, Department of Anesthesiology George Washington University (D.C.).
ASA Safety Tapes Should Get Annual Viewing
To the Editor:
The ASA and the Committee on Patient Safety and Risk Management are to be congratulated for producing the patient safety video series. These videotapes take a giant step in providing safety and risk management information to anesthesiologists and anesthetists.
I have concern that tapes may gather dust after
a first viewing and new department members and residents might be unaware of their presence. AU departments should be encouraged to establish an ongoing annual review of these excellent videotapes.
Bernard V. Wetchler, M.D., Director Departments of Anesthesia
and Ambulatory Surgery Methodist Medical Center of Illinois.
Fatigue Dangers Provoke Questions
To the Editor:
I would like to raise the matter of fatigue as a significant risk factor in anesthesia.
As is well known, airline pilots must be alert during their flights. And to that end, the FAA has had, for a long time, a strict program of work hours limitations to prevent tired pilots from piloting airplanes and thereby endangering passengers.
What may not be known is that the State of California (and perhaps other states as well) have analogous rules for truck drivers, and for the same reason that the hours that airline pilots work are limited.
The work of an anesthesiologist is at least as taxing and important as that of an airline pilot or a truck driver. Yet there is virtually no regulation, no standard for our activities namely, the number of consecutive work hours that an anesthesiologist can work before he is required to stop and get some rest.
There was a malpractice suit in California in which the judge directed a malpractice verdict against a surgeon who worked all day and kept on working so that he was up all night with emergencies. Then, when he went on to do his regularly scheduled 8:00 A.M. case he had a mishap. The Judge's action was based on his common sense, not on law, not on regulations, not on prior judicial rulings. His position, simply put was that no person, doctor or otherwise, who works all day and continues to work all night can be expected to perform optimally the next morning as well.
Yet this is exactly the situation in anesthesia many, many times. Why is it permitted?
I hate to say it but I think it is chiefly a matter of greed, income, dollars whatever you wish to call it. The remedy in this matter would be far more drastic than any of the activities of the Foundation to date. Regulation by some agency or authority of the hours one works which has a direct significant effect on income will cause howls like you never heard before
However, in order to make the case, though, on a rational basis, I would suggest two courses of action. One enlist (pay for) the support of scientists who are experts in the field of "shift work", which is exactly what we do. A second approach would emulate what the Highway Patrol does in California. Compare the incidents in anesthesia with the work history of say the previous 24 hours of that physician. This would require going into the insurance companies data bank and then doing detective work through other records all of which may not be possible because of rules of privacy.
I hope that this is a provocative letter. It is meant to be.
M. Jack Frumin, M.D. Atherton, CA
Fatal Potassium Error
To the Editor:
A tragic death from erroneous intravenous injection of concentrated potassium chloride solution instead of the intended diuretic precipitated a review of our handling of potassium chloride and other concentrated solutions throughout our hospital.
We could not identify any circumstances in which concentrated potassium chloride solution would be needed at a moment's notice. As we have 24-hour pharmacy intravenous preparation service, we withdrew the vials of concentrated potassium chloride solution from the OR, ICU, and other patient care areas to be held in the hospital's pharmacy. The pharmacy now prepares the diluted KCI solution ready for administration to the patient on receipt of a prescription.
This arrangement prevents a repetition of the previous accident, which we understand from the British Medical Defence Union is a frequent cause of accidental hospital deaths in Britain.
We have also withdrawn epinephrine in the 1: I 000 concentration (I mg in I ml) as this also is potentially lethal. There have been many reports of accidents when epinephrine was administered when ephedrine or Pitocin was intended. Epinephrine 1: 1 0,000 solution is the concentration now stocked in our operating rooms.
We would urge our colleagues to implement this policy wherever possible. In hospitals without 24-hour pharmacy service, we would recommend that concentrated potassium chloride solution be kept under separate lock and key to prevent accidental confusion between KCI and NaCl vials in the hospital's drug cupboards.
Floyd S. Brauer, M.D., Professor and Chairman and Leslie
Rendell-Baker, M.D. Professor, Department of Anesthesiology Loma Linda
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Is Your Central Gas Supply Tamper-Proof?
The mere presence of a skilled and certified anesthesia practitioner at the head of the operating table surrounded by the most advanced space-age monitoring can not by itself guarantee patient safety. The "technoglitz" of modern monitoring notwithstanding, patient safety, much like good detective work requires more perspiration than inspiration; it is a function of vigilance, planning, and training. Unfortunately, all too often, the operating room may be at the mercy of events that occur elsewhere in the hospital.
Recently, an employee of a hospital was interrogated by the police and later suspended after allegedly twice tampering with valves that regulated the pressure and quantity of nitrous oxide provided to an operating suite by a bank of cylinders. No patients were injured by the pipeline pressure fluctuations and at the time of the tampering, the pressure alarms promptly alerted the staff.
In a similar case, the main oxygen shut-off valve located in the hospital laundry room, was accidentally closed by an employee who thought that it controlled the central heating! A nearby sign identifying it as the main oxygen shut-off valve apparently went unheeded. Low pressure alarms functioned properly and alerted hospital personnel. The employee, sensing something was wrong, fled the scene. While there were no reports of problems in the operating rooms, several newborn infants were deprived of oxygen for several minutes, according to official reports of the event.
These two "near misses" demonstrate that patient safety requires more than just bedside skills. The recent shift in emphasis from environmental safety affecting all patients to issues of individual patient safety in a one-on-one setting should not lessen the importance of the former; rather it acknowledges that all anesthesia personnel now are expected to be familiar with the standards enforced by local jurisdictions and national accrediting bodies, such as the I.C.A.H.
It may be timely, however, to see if you can answer the following questions about your institution: 1) Is access to the shut-off valves properly controlled and locked?, 2) Are the supply systems in dedicated rooms or structures and not shared with the laundry?, 3) Can you locate the "emergency low pressure gaseous oxygen inlet" in the central patient gas supply? 4) Do you know where the two master alarm signal panels are as well as the area alarms for all anesthetizing locations? How recently were they tested?
For guidance in this area, anesthesia personnel have traditionally looked to the National fire Protection Association which in the past has issued pamphlets on the safe use of inhalation anesthetics (56A), non flammable medical gas systems (56F), emergency power (76A) and the safe use of electricity in patient care areas (76B) to mention but a few of their publications of importance to anesthesia. Recently, however, the N.F.P.A. has combined them into one authoritative manual entitled "NFPA 99-Health Care Facilities, 1987 Edition". This document (NFPA U8-99-87) should be in the library of all anesthesiologists and anesthetists; it may be obtained from the N.EP.A., Batterymarch Park, Quincy, MA 02269-9904 for S 17.50 plus a $2.85 handling charge. Monitoring may detect a problem, but knowledge can prevent one!
Topic Prepared by David E. Lees, M.D., Professor and Chairman, Department of Anesthesia, New York Medical College and a member of the APSF Newsletter Editorial Board.
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Editor's note: In each APSF Newsletter, a pertinent publication from the anesthesia patient safety literature ,will be summarized. Suggestions for future issues are welcome.
Gravenstein, J.S.: Essential monitoring examined through different lenses. I Clin Mon 1986; 2:22-29.
Dr. Gravenstein examines monitoring through three different lenses. Each reveals a different view as he scrutinizes the variables we monitor and how we have chosen them. Through @his examination we are shown the various forces which specify and mold our clinical practice.
Monitoring is classified according to its purpose, either to aid clinical management or to assist detecting and diagnosing physiologic aberrations. This paper concentrates on the latter.
Essential monitoring is equated with minimal monitoring and may be measured by the prevalence of monitor use. "Once a monitoring practice has been adopted by the majority of anesthesiologists, 51% to 99% that practice becomes a standard".
The first lens allows us to view monitoring as it affects outcome. Outcomes from anesthesia are classified as unremarkable or adverse. An outcome is adverse if it is remarkable because of prolonged hospital stay or impaired post-operative well-being (ill-being). Onset of ill-being is usually acute, but infections and other complications can have delayed onset. Duration can be either transient or prolonged.
Through one portion of this first lens, we see that it was not scientific data concerning outcome that led us to our current choice of monitors. Indeed, even after years of common use, we find no scientific evidence of improved outcome attributable to any of them. Nonetheless, some of our present monitors do stand the test of logical analysis. They seem to be measures of well-being or ill-being. They provide quantifiable data that guide us in protecting or improving our patient's state.
Unfortunately, for many measured variables, it is difficult to define the point at which well-being slips into ill-being. We have little data to determine what range of blood pressure is acceptable in any patient or population of patients. Indeed, thresholds for clinical action vary even among experts. As years have passed, our collective wisdom has shifted. Unacceptable hypotension of the 1940's (below 120180) became the acceptable hypotension of the 60's, 70's and 80's.
Thus, clinical practice has evolved extensively despite the lack of scientific data documenting changes in outcome.
The second lens explores the relationship between the variables we monitor and true measures of the patient's state. Dr. Gravenstein defines the patient's state as the state of the vital cell, a hypothetical cell which represents the heart and the brain. None of the variables we monitor let us view the actual state of the vital cell. At best, we view its input cascade. For the vital variable 'cellular oxygen tension', we monitor a series of variables which begin with pipeline oxygen pressure, pass through flow meters and a circuit-pressure gauge, and end with arterial oxygen saturation. Although we monitor numerous precursor variables, we are blind to the crucial variables that measure the state of the vital cell.
We thus acquiesce to monitor only the output of the vital cell to evaluate its state. Ideally, we would measure aggregate cellular output which represents electrical or chemical activity and is independent of organs and systems. Examples include the ECG which demonstrates electrical activity and is independent of mechanical performance. Temperature is another example. Instead, we usually measure integrated organ function (output) which fails to detect or identify specific state derangements. We do so because "monitoring has grown topsy-turvy and without the guidance of logic or insight".
The third tens clarifies the actual factors which have molded our monitoring practices; most are non-clinical. Anesthesiologists have been rigid in their ways and have resisted change. With many modalities, there has been a long delay from demonstration to adoption. This is because each newly offered variable was of questionable utility in clinicians' minds. Even capnography failed to gain acceptance in the U.S. until pulse oximetry eclipsed its impact.
To some degree, pressures from society, especially the legal community, have caused us to reassess our practices. "Lawsuits result as soon as the public recognizes that mistakes rather than fate may be responsible for an adverse outcome.. A verdict can firmly set a minimal standard."
In summary, most monitors considered essential were adopted by anesthesiologists because they believed that these monitors improved the outcome for the patient, even without scientific evidence. Only now are investigators beginning to measure the impact of monitoring on outcome.
Abstracted by James H. Philip, M.D., Director, Biomedical
Engineering, Brigham and Women's Hospital, Boston, MA.
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Monitoring Journal Stresses Safety Equipment
J. Clin. Mon. Is Central Source of Data
by N. Ty Smith, M.D.
Safety in anesthesia involves attention to detail and the ability to make proper decisions from the data available. The data comes from monitoring. To date, monitoring has been the major factor in the recent push towards total patient safety in anesthesia. The recent strong emphasis on monitoring has been so sudden that many of us have been caught unprepared for the rapid onslaught of changing technology, bewildering array of devices, and mandatory standards.
These drastic, relatively sudden changes in monitoring have forced us to buy expensive, sometimes complex devices that many anesthetists are not prepared to cope with; if they cannot cope with them, they may not use them, or they may use them improperly. Monitoring used improperly can be worse than no monitoring at all.
We need to know how to use our monitors, what they can do, what they cannot do, how to interpret the information that they provide, how to integrate the information from all of the monitors, how to troubleshoot a monitor, and when to buy a new one. Finding help in this area has not been easy, partly because the sources of information are so widely scattered: anesthesia, critical care, bioengineering, and engineering journals; obscure journals with limited distribution; poorly distributed proceedings; textbooks that are out-of-date before they are published, or literature from the manufacturer.
Unfortunately, even the information that has been available has not been sufficient. For example, there has not been enough information, other than anecdotal, to establish that any monitoring improves safety or saves lives. Information is also sparse on how to apply monitors and how to use the information that they give. The presence of a journal that encourages the exchange of information on these topics will help increase the availability of that information.
The Journal of Clinical Monitoring has approached these problems in many ways. First, it has improved communication between the innovators and manufacturers on the one hand and the users on the other, emphasizing clarity of presentation. We do not receive the technical training in medical school; they do not have the clinical insight that requires years to accumulate. Only by understanding each other can monitoring improve safety.
The Journal has strived to improve safety in many ways, most of them quite conventional: original articles, reviews, tutorials, medical intelligence, and case reports. The early years of monitoring emphasized the cardiovascular system. Lately, however, it has become apparent that over half of the major critical incidents are related to a lack of supply of oxygen to the tissues. Thus, the newer monitoring equipment has shifted towards respiration, a shift that is reflected in the journal. As a matter of fact, the Journal seems to be caught up in this trend: about one-third of its submissions are related to respiration, including pulse oximetry, capnography, and mass spectrometry. These are the very areas where a rapid dissemination of knowledge is essential for safety.
In exploring new ways to improve safety, the journal has been as practical as is consistent with W science. One of the most popular of the Journal's innovative sections is the Clinical -Controversies, which has covered such topics as where should a central venous catheter be placed, when should it be placed, do we monitor too much, which is better the pulse oximeter or the transcutaneous oximeter, are evoked potentials useful in the OR, should we monitor alveolar and inspiratory concentrations of anesthetic and respiratory gases?
Future Controversies ask equally important questions: does monitoring make a difference in patient safety? Now that we have oximeters and capnometers, do we need continuous stethoscope monitoring Should we monitor patients receiving epidural opiates? Does mean arterial pressure have any physiological significance? Does one need a waveform with a capnometer? Is measuring drug concentrations needed in the OR? What one monitor would you take to a third world country?
Another feature that promises to be equally useful is one that will start in the next issue: "Knowing Your Monitoring Equipment". In this section we shall ask the designers and manufacturers of commonly used monitoring equipment to explain how the equipment works and how it should be operated. Frequently such information is not available to the clinician because the manuals that come with the equipment often do not answer all the questions, sometimes they are written mom for the engineer than for the physician, and finally most equipment comes with only one manual, which is needed by many and often not available when needed.
The first essay will deal with the new method of continuous blood pressure employing the Penaz method, which is incorporated into a device marketed by Ohmeda under the trade name Finapres TM. In preparation is an essay dealing with infrared capno8raphy. In the planning stage are papers on pulse oximetry and electrocardiography. Readers who collect their issues of the Journal of Clinical Monitoring will accumulate over the years a valuable library on the operation of commonly used monitoring equipment.
Sometimes safety appears in the least expected places. For example, there is work on an EEG-based algorithm for detecting awareness during anesthesia. A reliable method for detecting awareness is important, because of the tendency to give an excess anesthetic to cover all patients, with possible unpleasant intraoperative or postoperative consequences for the occasional patient who is too sensitive to the anesthetic.
Monitoring will continue to change, and to change rapidly. Thus, the Journal will help the clinician prepare for the future by emphasizing now the future: automated record keeping, including voice recognition; servo control of drugs, machines, ventilators, etc.; monitoring of drug levels; continuous intravascular monitoring; and specific technologies, such as Raman spectroscopy.
This is your journal. Although the Editorial Board can assure high quality and readability, only you can let us know how well we have succeeded in our goals whether we have succeeded in helping you improve on patient safety in the operating room. What type of material or topics do you need to help you implement this important goal?
And please consider the journal as a medium for transmitting your ideas and thoughts to your colleagues. Manuscripts are always welcome. If you are interested in submitting a manuscript, please read over the Information for Contributors, to be found in the back of each issue. If you are interested in a subscription, either for yourself, or for your hospital, school, or departmental library, please contact Little, Brown and Co., 34 Beacon Street, Boston MA 02106, (617) 890-0250.
Dr. Smith, (an editor of the Journal of Clinical Monitoring), Department of Anesthesiology, V.A. Medical Center, San Diego, CA; is also an APSF Director.
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by J.S. Gravenstein, M.D.
The Anesthesia Patient Safety Foundation sponsored a workshop entitled "SAFETY AND COST CONTAINMENT IN ANESTHESW' on February 27 and 28, 1987. It was hosted by the Department of Anesthesiology of the University of Florida in Gainesville and made possible through a generous grant from Ohmeda.
Anesthesiologists, attorneys, insurance experts, manufacturers, and risk managers were the invited participants. While these professionals interact on many levels, they rarely have an opportunity to exchange ideas and they often find it difficult to understand what motivates their counter parts. The workshop was divided into several sections:
Setting the Stage
Dr. W.K. Hamilton from the University of California, San Francisco opened the meeting with a timely reminder that we have permitted anesthesia care to become more expensive than is necessary for the sake of safety. Then, Dr. F.W. Cheney from the University of Washington in Seattle offered an overview of the risks associated with anesthesia. He and his coworkers concluded from an analysis of national closed-claims data that better monitoring might reduce anesthetic mortality.
While we know that anesthesia does cause some patient morbidity and mortality, even among the healthy undergoing minor operations, it is most difficult to obtain scientifically valid statistics on the true incidence. What is known about the epidemiology of anesthesia as it relates to untoward events and the problems that have plagued workers in this field was discussed by Dr. I.B. Forrest from the University of Ontario.
The Financial Impact of Adverse Outcomes in Anesthesia
Perspectives on the financial impact of adverse outcomes in anesthesia were discussed from several vantage points: by an economist, Kay Plantes, by Mark D. Wood from the St. Paul Insurance Company, by James C. Rinaman, Jr., an attorney, by Burt A. Dole, president of Puritan-Bennett and, finally, by Dr. P.O. Bridenbaugh from the University of Cincinnati. Workshop participants were astonished to learn how far the consequences of a mishap in the operating room can reach and that some of the ripples are magnified into veritable tidal economic waves affecting not only physicians and their insurance premiums but also the companies and their ability to finance research and development. The section vividly demonstrated the extraordinary interdependence between the anesthesiologist, the hospital, and the many professionals who supply equipment, insurance, or defense when necessary. Dr. Bridenbaugh echoed points raised by Dr. Hamilton: defensive medicine may increase the cost of anesthesia care; but there is hardly an anesthetic that could not be rendered less expensive without sacrificing safety.
How to Improve Safety in Anesthesia
A section dealing with ways to improve the safety of anesthesia was introduced by I.E Holzer, an attorney-risk manager from Boston who described the role of the risk manager. What anesthesiologists can do to adopt safe practice patterns was reported by Dr. S.M. Duberman from New York. Dr. E.C. Pierce, President of the Anesthesia Patient Safety foundation, recounted the steps for greater safety taken by the profession as a whole. That the efforts of physicians and risk managers cannot exist in vacuum was the theme of W. Cleverley, a health care finance specialist from Columbus, Ohio, and G. Gore a defense lawyer from Cleveland, Ohio. Dr. Cleverley discussed the difficulties faced by hospitals in a world of changing rules under which capital expenses and operating costs are reckoned. Mr. Gore reminded the audience that adherence to fairly simple and well recognized rules will not only increase safety but also make it easier to defend an anesthesiologist in court, should that ever become necessary.
How Financial Decisions Touching on Safety are Made
In a section on financial decision-making for safety and thrift, the different players in the field were introduced to each other. Each makes demands on the other and each faces constraints. The budgeting process and the competition among clinical department heads in a large-for-profit hospital, was described by Mr. I.M. Birnbaum, an attorney and administrator from New York. The budgeting process in a large for-profit hospital chain was explained by Mr. P. Powell from Humana. The clinician's perspective was presented by Dr. J.H. Modell from the University of Florida.
What everyone wants to know, namely how insurance premiums are set was revealed in a spirited exposition by Mr. P. Sweetland from the New Jersey Physicians Insurance Company. Finally, Mr. T. Gibson from Ohmeda explained why and how the financial impact of safety in anesthesia pinches the manufacturer. The-physicians who were unaware of the repercussions faced by manufacturers learned about the far-reaching consequences of clinical successes and failures in the operating room.
Current Issues that Affect Safety and Cost
Several speakers addressed timely problems that confront the specialty. Dr. R.J. Kitz from Harvard presented the history of the Harvard and ASA minimal monitoring standards and viewed these within the framework of other general standards that have long since become almost unnoticed in the fabric of our society. Of course, standards have their drawbacks and these were enumerated by Dr. R.K. Stoelting from Indianapolis. Even the best standards on monitoring will contribute little to safety if the clinician on the scene cannot respond to signals presented by the monitors. Thus, education of anesthesiologists and nurse anesthetists may play as big or bigger a role than standards for monitoring. Dr. A.L. Schneider from Hershey, Pennsylvania reported on the current educational requirements in anesthesia which appear impressive, until one looks at performance standards well established in other fields, such as the aviation industry. Captain B. Beach from Eastern Airlines informed the audience on the exacting and well established performance standards in commercial aviation. The contrast was striking.
Commercial aviation, of course, is used to another standard that has no equal in medicine, that of the so-called black box. These devices record both the voices in the cockpit and much data on the performance of the plane and its engines during a flight. In anesthesia, we still generate hand written records that may or may not contain the information that would allow not only timely clinical decisions but also an analysis of problems, should an adverse outcome have resulted because or in spite of the efforts of the medical team. Dr. C.E. Whitcher from Stanford described the first generation of automated anesthesia record systems and their advantages, while Dr. 1. Eichhom from Boston detailed the potential disadvantages, including the concern that the automated record keeping devices has engendered among some who fear automatically recorded artifacts and, also, the absence of both helpful and incriminating data on the hand-written anesthesia chart.
The Proceeding Will Be Published
All participants praised the opportunity to exchange opinions and concerns with representatives from different fields, all of whom contribute in their own way to anesthesia and the safety of patients. The proceedings of this unique workshop will be published by Butterworths and the date of publication will be announced in the APSF Newsletter.
Dr. J.S. Gravenstein, University of Florida, is on the
Executive Committee, Anesthesia Patient Safety Foundation.
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Question: My department of six physi6ans and eight CRNA's has no real quality assurance pro8ram. How do we get started?
Answer: Learning which a departmental quality assurance program involves a series of steps that include:
(1) Learning which activities should be included in a quality assurance program and what these activities involve.
Departmental quality assurance programs are instituted in order to ensure that good quality patient care is both possible and present within the department. It is necessary to determine that conditions are adequate to provide good care (in terms of staff qualifications and numbers, physical facilities, equipment, and other resources, and administration); that good care is provided by department members; and finally that outcomes are appropriate
Activities that help to meet these goals include problem identification, evaluation, resolution, and reassessment to ensure resolution; evaluation of appropriateness of care; proper maintenance of equipment and other resources; monitoring of events and trends; and establishment of appropriate standards, guidelines, protocols, or policies.
Relevant literature and techniques for carrying out these activities should be explored.* Learning about the experiences of colleagues who have already set up quality assurance programs in their own departments is very helpful.
(2) Identifying the individual(s) or committee responsible for setting up the program.
To be effective, departmental review and evaluation of patient care should involve as many staff as possible.
The support and input of the chairman is crucial if the plan is to be taken seriously. In addition, when the issue of provider performance is raised, it may be appropriate for the chairman to act through established channels created by the medical staff bylaws or other hospital procedures, rather than through a departmental committee
All members of the department should have input into the planned quality assurance activities and should understand what will be expected of them in terms of compliance with criteria for evaluation of care and with specific policies.
However, for any quality assurance activity to be carried out successfully, it is important to identify the individual or committee responsible for implementation of that specific activity, and to ensure that the responsibility is recognized. This is equally true in identifying those individuals responsible for gathering the information necessary to set up the quality assurance program and for writing an initial plan to be reviewed and commented on by other members of the department.
(3) Identifying regulations and requirements that will affect the form and/or content of the program.
Requirements and regulations placed on the anesthesiology department by the hospital, the state and federal governments, and the JACH affect the administrative form of the program, the specific activities carried out, and the content of criteria and policies. These rules and regulations should be investigated when planning the program. Also, the public health laws governing the discoverability of quality assurance findings and the protection of medical personnel involved in quality assurance activities vary from state to state. Proper handling of matters such as maintaining confidentiality of data, writing of policies, methods of documentation and reporting, and dealing with issues of provider performance must be considered.
Therefore, in establishing or altering a quality assurance program, appropriate legal counsel should be sought.
(4) Assessing existing departmental and hospital quality assurance activities that can be included or adapted for inclusion.
Many of the activities necessary to a departmental quality assurance program may already be in place, although some may not be well coordinated or documented. It is important to inventory all existing department activities related to quality assurance as the preliminary plan is developed. For some activities it only will be necessary to document what is already being done. For some activities it will be possible to determine that expansion, reorganization, or modification can result in quality assurance activities that meet current expectations or requirements. For other activities it will be necessary to develop new parts of the program. AU of these activities eventually can be integrated into a consolidated quality assurance program.
The organization of the hospital's quality assurance program and the hospital's facilities can have significant effects on the mechanics of the departmental program. Utilizing available data sources and personnel from the hospital may avoid duplication of work, thereby reducing time, effort, and cost. The hospital may employ quality assurance nurses or other personnel to help the department, or the record room may be able to retrieve pertinent data from charts. These opportunities should he thoroughly investigated.
(5) Using this information to develop a quality assurance plan to meet the specific needs of the department.
While many of the techniques applied to, and the problems identified from, quality assurance activities will be similar from department to department, no two departments are identical. There are variations in staffing, patient characteristics, numbers of patients, surgical procedures, anesthetic procedures, locations of services, local requirements, affiliation, teaching status, and unique problems and issues. All these must be considered when developing a program that will meet the specific needs of the department.
It is important to remember that setting up a quality assurance program is only the first step in running a successful program. Quality assurance programs evolve as problems are identified and solved and new ones are discovered, as techniques are found to be inadequate for the needs of the department and are changed, as requirements change, and as new methods of quality assurance develop. These programs should be periodically reviewed and revised.
Answer by Stephanie M. Duberman, M.D., Columbia University, New York and a member of the 9-ISF Board of directors.
*Editor's Note: "Quality Assurance in the Practice if
Anesthesiology 1986," written by Dr. Duberman, was published in October
1986 by the American Society of Anesthesiologists. It expands on the material
summarized in this column and covers additional topics. It also contains
a bibliography that will help individuals find information about quality
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State Society Focuses on Needed Changes
by Robert W Vaughan, M.D.
Recognizing the need for personal involvement by individual anesthesiologists, the North Carolina Society of Anesthesiologists (NCSA) organized its 1986 annual meeting in Asheville to focus on a comprehensive strategy to link safety in anesthesia with a plan to implement risk management.
Speakers included Burton A. Dole, Jr., Chairman and President, Puritan-Bennett Corporation, John H. Eichhorn, M.D., Harvard Medical School, Boston; Ellison C (Jeep) Pierce, Jr., M.D., President, Anesthesia Patient Safety Foundation, New England Deaconess Hospital, Boston; William D. Petasnick, Director of Operation, North Carolina Memorial Hospital, Chapel HUI; Robert W. Vaughan, M.D., Professor and Chairman, Department of Anesthesiology, University of North Carolina at Chapel Hill; and Mark D. Wood, Medical Services Manager of Risk Management Division, St. Paul Fire & Marine Insurance Company.
Moderators from the NCSA were Drs. Jerry Calkins and Dana Hershey (President). In organizing this seminar, NCSA leadership in private practice and academics recognized that the current crisis in the cost of medical liability insurance mandates that attention be directed toward risk management and patient safety to reduce the number and severity of anesthesia-related mishaps, For example, although the percentage of anesthesia medical liability claims involves only three or four percent of the total for all of medicine, the indemnity paid out exceeds I 11%. This underlines the importance of severity in the anesthesia cases and the absolute need to reduce risk, especially for hypoxia. Strategy should include combining facts, time, and effort directed at a safety program while working toward the more lengthy process of tort reform.
The program was structured for the first day to define the problems of risk management and liability and on the second day to propose solutions to the problems from different perspectives (i.e., the national and state level, the insurance industry, the manufacturers' viewpoint, the hospital administrators' overview, and a comprehensive strategy for linking a focus on patient safety, risk management, and malpractice reform).
Dr. Eichhorn opened the seminar by enumerating the enormous settlements and judgments presently drawing attention in the news media. He noted that anesthesiologists in their practice were more likely to be involved with severe, debilitating injuries than most other physician specialists; that possibly up to 2,000 ASA I patients die per year in the United States; and that a significant number of these deaths from available data appear to be preventable. In reviews of closed and open anesthesia-related claim abstracts, he enumerated that certain types of problems recur while variations in classification make comparisons difficult. These common complications include inadequate ventilation, difficult endotracheal intubation, esophageal intubation, accidental extubation, ventilator disconnects, bronchospasm, and relative or absolute anesthesia overdosase. However, anesthesiology is uniquely fortunate in that early detection of mishaps through use of newer sophisticated monitoring and technological advances is likely more possible than in any other specialty. Moreover, if one were to compare the purchase cost of monitoring devices with the skyrocketing cost of medical liability insurance, the capital outlay for monitoring equipment becomes small indeed. Dr. Eichhorn summarized his opinion regarding the solutions to the malpractice crisis as follows: tort reform extremely unlikely; insurance reform extraordinarily unlikely; system reform essentially impossible; and reduction of patient injuries the only hope. Our job as anesthesiologists seems clear.
Mr. Wood then presented the perspective from the insurance industry by explaining that insurance indemnity functions as a system of risk sharing where the financial resources of the group are made available to pay for the losses of individual members. The biggest problem in insuring the anesthesiologist is the fact that when the losses do occur, they frequently are catastrophic in nature.
For example, preliminary dosed-claims data demonstrate that 22% of cases were hypoxia related, those cases consumed 57.2% of the indemnity, the per case cost was $403,500, and that, alarmingly, 80% of cases were ASA I and If patients. He emphasized that the solution for any anesthesiologist becomes an unwavering resolve to improve the efficacy of anesthetic techniques and to make the best use of available technology for early diagnosis and treatment of hypoxemia and reduction of iatrogenic injury to patients due to anesthetic administration.
Mr. Dole explained the viewpoint of the anesthesia equipment industry on safety and risk management. Noting that users and manufacturers of health care equipment are merely different a= of the same effort, he outlined the status of Puritan Bennett (P-B) as a leader in critical health care research and manufacturing. However, despite P-B products' excellent safety record and despite modest liability claims and settlements, product liability insurance cost rose 656% in 1986. Their cost per $ 1,000 of insurance coverage increased 2700% for the same period while three of their primary insurance carriers become insolvent.
The tort system in 1986 is broken, expensive, inefficient, slow, and wasteful. As a result, industry is being forced to raise prices at a time when the national priority is to control costs and reduce health care expenditures. Consequently, an overwhelming demand has occurred for new legislation in order to guarantee a more reliable and predictable method of assessing damages and fault. As a plan for action, he noted that in the voluntary sector, representatives of the Health Industry Manufacturers Association are meeting with their counterparts at the American Medical Association in an effort to present a more unified
front in the health care field to gain much needed tort reform in liability coverage. In much of the business and industry of health care, new research and development monies are being channeled towards patient safety and reduced labor costs. As the home health care market expands, rapidly increased attention is being given to the safe use of such products and the associated potential of liability risk. Mr. Dole closed by emphasizing that a major step forward has been taken with the establishment of the Anesthesia Patient Safety Foundation to focus specific resources of personnel and funds on an educational program for anesthesiologists. This unique effort is targeted to develop grassroots interest in patient safety and risk management. He noted that we need to change public perception. "We are doing a good job. Why are we on the defensive rather than the offensive?"
Mr. Petasnick discussed the malpractice reform issue from the standpoint of hospital administration. "This is a team effort a partnership!" He noted the shared responsibility of the hospital and anesthesiologists to ensure a safe environment, the cost effectiveness of risk avoidance, and realistic strategies to work out a collaborative relationship between hospital administration and the medical staff. Mr. Petasnick's experience has been that in many operating rooms in hospitals in North Carolina, anesthesiologists have begun to expect automated, non-invasive blood pressure apparatus; pulse oximeters; and even end-tidal PCO2 devices in addition to the already present electrocardiogram, oxygen analyzer, high and low pressure alarm, and temperature monitoring capabilities. He noted in his own institution how he had heard frequently from anesthesiologists emphasizing safety and risk management. Moreover, surgeons were beginning to recognize the early warning signal of the oximeter registering desaturation at unexpected moments as well as during endotracheal intubation. Pulse oximeters are even proceeding into the recovery room to aid in patient management and safety. There seemed no doubt that many large liability awards for hypoxic accidents could have been prevented by the provision of better monitoring equipment for the anesthesiologists. He further emphasized that with the constraint on the hospital capital equipment budget, an honest and realistic assessment rather than a "wish 6t" would demonstrate integrity and promote relationships necessary to help negotiation among health care colleagues. He applauded anesthesiologists for taking the lead in managing risk and being the first to emphasize patient safety. Mr. Petasnick closed by asking anesthesiologist leaders to approach their hospital administrator with a comprehensive three- to-five year plan including full disclosure of initial cost and maintenance, personnel (upgraded if necessary) needed for the new technology, a prioritized list of needs, and to maintain an ongoing dialogue using the candor necessary to build trust and understanding.
Dr. Pierce shared with the audience the genesis of the Anesthesia Patient Safety Foundation. In October, 1984, the first meeting of the International Symposium on Preventable Anesthesia Morbidity and Mortality was held in Boston under the auspices of the Royal Society of Medicine Foundation and the Harvard Medical School. Following this successful international meeting of invited experts, symposium members considered the future direction should include establishment of a safety foundation. Subsequently, the 1985 House of Delegates of the American Society of Anesthesiology embraced Dr. Pierces proposal for a safety foundation. The Anesthesia Patient Safety Foundation was established as an independent organization with 50% of its board of directors as ASA members and an administrative support office at the ASA headquarters in Park Ridge, Illinois. The 30-person board of directors has been constituted to include 15 anesthesiologists, as well as representatives from equipment manufacturers, CRNA anesthesia, the insurance industry, the legal profession, the American Hospital Association, and the Federal Food & Drug Administration. The mission established was "to insure that no patient shall be harmed by the effects of anesthesia."
Dr. Pierce has gone on record by stating that "today it is simply unacceptable to allow cost containment and inertia to prevent utilization of state-of-the-art anesthesia and monitoring apparatus. No government official or hospital administrator would ever fly in an airplane without up-to-date equipment and safety devices." The only difference Dr. Pierce stated in the deaths that he can see is that "anesthesia deaths occur one at a time, whereas in the airline industry they occur in large numbers at once".
Revolution and Crisis
Dr. Vaughan was asked to give an overview of the health care revolution in which we find ourselves, the liability crisis, and reflect on how our health care colleagues can become allies in the battle. He noted that our U.S. health care revolution includes tremendous cost (over 460 billion dollars spent in 1986 on U.S. health care); population demographics with aging and increased health needs and costs for Medicare and Veterans Administration recipients (Table 1); a huge budget deficit developed over that last six years (greater than one trillion dollars) introducing the severe political crisis in how to control costs; the enormous technology changes that seem almost beyond our ability to afford; and the ethical and moral dilemma presented to physicians to decide who lives, who dies, and who gets how much of what cam The liability coverage issue has become one of unavailable insurance coverage for small business and high risk providers as well as affordability for high risk providers especially with capitated reimbursement schemes (i.e., Massachusetts).
Despite U.S. health cares success in becoming a miracle, an exportable resource, the envy of the world, and phenomenal, it has been severely
criticized as inefficient, wasteful, subject to abuse and responsible for collosal costs in an emerging "medical arms race7' for lithos (helicopters), lithos (lithotripters), and nucleos (MRI's). Dr. Vaughan summarized the "malpractice lottery" as involving four players (Figure 1). The loser on all accounts becomes American society with maldistribution of minimal benefits for the exorbitant cost of settlements. The present system appears out of control. For example, while $.30 of each malpractice dollar goes to the victim of malpractice, $.70 goes to overhead expenses to reimburse lawyers, court costs, and expert witnesses. Dr. Vaughan suggested a plan which would start with the individual anesthesiologist, having each emphasize a program of saw and risk management by focusing on better monitoring and standards for each of our practices (Figure 2). An ongoing participatory dialogue would address the tort reform issue over time enlisting the assistance of our health care allies in an all out effort to eliminate the malpractice lottery and distribute appropriate compensation to injured patients and family.
Finally, all speakers agreed that anesthesiology was a specialty uniquely positioned to control its fate in terms of risk management. The members of the North Carolina Society of Anesthesiologists agreed in subsequent discussions that the tort system was indeed broken, wasteful, inefficient and unfair, and quite slow (three to five years) to settle claims. North Carolina anesthesiologists are attempting through their practices to demonstrate commitment to the principles enumerated by the Anesthesia Patient Safety Foundation while continuing to speak actively to government and employers as patient advocates in health care.
Dr. Vaughan is Professor and Chairman, Department of anesthesiology, University of North Carolina at Chapel Hill.
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Post-Anesthesia Nursing Standards Available
The ASPAN (American Society of Post Anesthesia Nurses) Standards of Nursing Practice have been revised and are available for purchase through the ASPAN office.
These updated Standards now include the following areas
Ambulatory Surgery Unit
The Standards are based on the concept of the Nursing Diagnosis and the Nursing Process and include Management Standards as well as Clinical. The American Society of Anesthesiologists has recently endorsed these Standards, available in a convenient handbook size.
ASPAN MEMBERS ......... $5.00
NON-MEMBERS .......... $7.00
Available through the ASPAN administrative office. P.O.
Box 1 1083, Richmond, VA 23230.
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 & 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.[)., Secretary; Burton A. Dole, Jr., Treasurer; Jeffrey B. Cooper, Ph.D.; Joachim S. Gavenstein, M.D.; James E Holzer, J.D.
Newsletter Editorial Board:
John H. Eichhorn, M.D., Stanley J. Aukburg, M.D., Jeffrey M. Beutler, C-R.N.A., M.S., Ralph A. Epstein, M.D., David E. Lees, M.D., E.S. Siker, M.D., Bernard V. Wetchler, M.D., Mr. Mark D. Wood
Address general correspondence to: Administrator
Anesthesia Patient Safety Foundation 515 Busse Highway
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