Volume 11, No. 4 • Winter 1996

APSF Success Seen in Work, Start of AMA Foundation

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

The Anesthesia Patient Safety Foundation (APSF) is now eleven years old. Its significant success may be glimpsed in a recent headline and article in the Washington Post: Anesthesiologists Have Led The Way Toward Reform. It states, “No medical specialty has made more progress in improving patient safety and reducing errors than anesthesiology. Medical experts say much of the credit for these improvements is credited to the Anesthesia Patient Safety Foundation, a ten-year old effort that has sharply reduced injuries and deaths, according to Harvard researcher Lucien L. Leap.”

In an associated article, the Post also noted that: “The AMA… plans to establish the National Patient Safety Foundation, a non-profit organization that will fund research into the causes and prevention of medical errors. The foundation, which is to begin operating in January of 1997, will also serve as a clearinghouse for information on patient safety. The group will be modeled after the Anesthesia Patient Safety Foundation, a group founded by anesthesiologists ten years ago that has sharply reduced death and injuries from anesthesia errors, typically the most catastrophic in medicine because they are more likely to result in brain damage or death.” All those associated with the APSF should be particularly proud of the recognition given our organization through the creation and naming of the parallel AMA foundation.

Editor’s Note: the November 18, 1996 American Medical News carried an editorial entitled, “An open, constructive approach is the better way to improve patient safety; ending the blame game” describing the founding of the AMA National Patient Safety Foundation and also noting that anesthesiologists have “led the way” with the APSF.

For the APSF, this has been another good year. The number of corporate donors to the Foundation continues to increase. APSF is now on the net (the address is on the APSF Newsletter masthead). The Newsletter this year described the new ASA videotape that focused on Perioperative Peripheral Nerve Injury and reviewed the wide spectrum of safety points seen at the 1995 ASA Meeting. It noted that the ASA exhibits continued a wide safety theme in the scientific and technical exhibits. It described the five research grants given by APSF in 1996, promoting safety research.

Jeffrey B. Cooper, Ph.D., reviewed the ten-year program of the safety research grants, which have contributed more than $1.3 million through some thirty-five awards. Results from these APSF funded research undertakings have been significant. The continued development and growth in the numbers of anesthesia departments with simulator programs were evaluated.

J.S. Gravenstein, M.D., carefully reviewed the problems and solutions in using “obsolete” old anesthesia equipment. Ervin Moss, M.D., again emphasized the dangers associated with contaminated oxygen supply systems in hospitals, including recent deaths.

The April meeting of the International Committee on Prevention of Anesthesia Morbidity and Mortality was examined. It was noted that the ASA Patient Safety Videotape Series is now available to be seen on the Internet, using an inexpensive audio video conferencing program called CUSeeMe. The details can be found through the APSF net address. Carl S. Hug, Jr,. M.D. reviewed remifentanyl and its safety issues. Lastly, Dr. Moss examined the New Jersey experience in mandatory incident reporting mechanisms. This approach to safety clearly should spread to more states.

Following many requests across the country over several years, APSF has published a soft cover compendium of major articles of the first eight years of the Newsletter, 1986-93, which is available from APSF headquarters for $24.50. Drs. Robert Morell and John Eichhorn and have published a new book entitled, Patient Safety in Anesthetic Practice, which is a very thorough review of subjects in safety.

On the downside this year, I have learned of several anesthesia mishaps which were probably avoidable and which resulted in patient death. In my 1995 Rovenstine Lecture, I quoted Nik Gravenstein: “We must raise our voices in support of safety. If we do not, safety will take a back seat to economy.” We must never abandon our goals.

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