Front page of the first issue of the APSF Newsletter, Vol. 1, No. 1, March 1986, with a photo of the first APSF Executive Committee members.

When the Anesthesia Patient Safety Foundation was created in the Fall of 1985, with the admirable mission “that no patient shall be harmed by anesthesia care,” an agenda of communication, education, advocacy, debate, and research support was begun that continues enthusiastically in force to this day.

The first issue of the APSF Newsletter, in March 1986, immediately embraced the current issues of that era: essential intraoperative monitoring, risks of hypercarbia vs hypoxemia, verification of correct endotracheal tube placement, lessons from closed claims, and grant support for much-needed high-quality patient safety research. Some of the early questions and concepts have been resolved or significantly transformed over time—others, not so much. Review of every issue of the Newsletter, in order since its creation, reveals that many concerns recur over the decades.

Previously published histories have detailed the antecedents, driving forces, and organizational efforts to launch the APSF, as well as its role in establishing, naming, and defining the discipline of patient safety, and as the first formal patient safety organization.^1-3 Note that the APSF was prominently cited as the prototypical example of a formal organization helping to improve patient safety in the landmark (and controversial) comprehensive 1999 “To Err Is Human,” report from the Institute of Medicine,^4,5 which resulted in an APSF response from then APSF President Robert K. Stoelting, MD, (successor to inspirational founding APSF President, the late Ellison C. [“Jeep”] Pierce, Jr., MD) highlighting the significant recognition of APSF, but objecting to the report’s emphasis on identifying and eliminating “unsafe providers,” as opposed to preferred objectively proven system-based protocols and efforts.⁶

Within the initial year of the APSF, the American Society of Anesthesiologists (ASA) adopted the first ever formal mandatory standards for intraoperative monitoring,⁷ with the strongest possible backing of the APSF, especially through the involvement and efforts of Dr. Pierce (past ASA president, who initiated its standards committee) and John H. Eichhorn, MD, (then APSF Newsletter editor, secretary of that new ASA standards committee, and chair of group that created the original Harvard monitoring standards).⁸ Over its first few years, the APSF supported, endorsed, and publicized both the updating of the ASA standards and the creation and adoption of intraoperative monitoring standards by numerous anesthesia societies and governments from all around the world.

John H. Eichhorn, MD, founding editor and publisher of the APSF Newsletter.

Multiple areas of patient safety interest have received intense APSF efforts over the decades. Good examples include safety issues related to non-OR anesthetizing locations (MRI, cath lab, etc.) and office-based anesthesia. Anesthesia automated electronic information systems and their electronic anesthesia records (with debate and mixed opinions about safety implications) have been often considered. Patient-injury fires during monitored anesthesia care with open supplemental oxygen being administered to the sedated patient generated major safety recommendations and is the subject of one of the APSF Executive Summary videos (intended for both professionals and patients) available on the APSF main webpage. Patient vision loss after prolonged prone spine surgery was a critical issue that APSF fixated on more than 15 years ago and publicized widely, encouraging preventive protocols. A related concern is hypotension and adverse events in patients anesthetized in the beach chair position, often for shoulder surgery. This issue surfaced in 2007,⁹ was the subject of a 2009 APSF Workshop,¹⁰ provoked the creation of an APSF registry of injury cases in 2010, and led to several preventive practice recommendations. Safety implications of distractions in the OR, yielded a series of recommendations for practice and provided another example of the recurring nature of safety issues in anesthesia.¹¹ The topics of distraction (especially “reading” in the OR, which produced for years a torrent of Letters to the Editor in the Newsletter), practitioner fatigue, and, later, OR production pressure (usually with institutional financial motives) have intermittently permeated throughout APSF efforts for decades. Monitoring neuromuscular blockade by muscle relaxants during, at the end of, and even after general endotracheal anesthesia has been (and continues to be) an intense and heavily debated issue for the APSF. These discussions have highlighted quantitative neuromuscular monitoring technology¹² and contributed to the eventual adoption by the ASA of specific practice guidelines to enhance patient safety.¹³ Surgical infections were another topic that received significant attention.^14,15 The implications and challenges of the COVID-19 pandemic were addressed by the APSF, especially the use of anesthesia machine ventilators in make-shift emergency ICUs set up in operating rooms.

The APSF Newsletter through the years, starting with the original design under John Eichhorn; changes to the logo and format under Bob Morell; and our latest edition with the new branding under Steven Greenberg.

Closely related to human factors in anesthesia patient safety are the topics of crisis management, emergency manuals, cognitive aids for use in clinical practice (both emergency and routine), checklists, and hand-off communications. The APSF has awarded research grants on technical and nontechnical decision support tools for perioperative pediatric crises, sponsored Pierce Memorial lectures on the importance of cognitive aids, and organized conferences on the implementation of cognitive aids and checklist in the perioperative setting.^16-18 Checklists as a tool to enhance anesthesia safety (and the classic analogy comparing administering anesthesia to piloting a commercial jumbo jet) appeared very early in APSF discussions;¹⁹ anesthesia machines and equipment were the first checklist targets.²⁰ The APSF administered a profession-wide survey to help formulate a template for a pre-anesthetic checklist.²¹ More recently, proposals for implementation of checklists have focused on handoffs between caregivers. Formed in 2015, the Perioperative Multi-Center Handoff Collaborative is supported by the Anesthesia Patient Safety Foundation.²² The inaugural APSF Stoelting Conference yielded recommendations for handoff procedures to enhance patient safety.²³

The APSF has periodically conducted surveys of anesthesia practitioners to help determine the relative priorities in order of importance from a list of more than 50 specific patient safety ideas: in 1999²⁴ (difficult airway management was number 1); in 2018²⁵ (perioperative clinical deterioration and responses topped the list); and in 2021²⁶ (“culture of safety, inclusion, and diversity” was the first priority). The ordering of the priorities ranked in the surveys has changed some and progressed over the years, but, as noted, reviewing those lists, most of the fundamental questions persist, thus providing stimulus, inspiration, and direction for APSF engagement in both the present and the future.

John Eichhorn, MD, was the founding editor and publisher of the APSF Newsletter. He lives in San Jose, CA, as a retired professor of Anesthesiology, and continues to serve on the APSF Editorial Board.

The author has no conflicts of interest.

REFERENCES

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