Circulation 36,825 • Volume 17, No. 3 • Fall 2002

European Society Develops On-Line Help System

Azriel Perel, MD

Anesthesiologists need and rely on a tremendous, and ever increasing amount of information to support informed, real-time decisions. Lack of sufficient knowledge about underlying medical conditions, drug dosages (a well documented source of error), and procedural considerations, may be an important and relatively underestimated source of error in anesthesia. Other factors that may contribute to potential sources of error include a lack of active learning and inadequate monitoring of physicians’ knowledge and medical skills. In addition, the growth of practices outside major hospitals, coupled with cost-containment and production pressures, may lead to the provision of anesthesia by personnel with inadequate knowledge and inadequate supervision. Interestingly, though many studies have identified “human error” as a significant reason for perioperative adverse events, there are nearly no studies that have attempted to examine the specific role of insufficient knowledge as a possible source of such error. One study did find “inadequate knowledge” and “lack of alternative plan” to be among the major reasons for anesthesiologists’ errors in the operating room.1

As a result, the European Society of Anaesthesiologists (ESA) has taken the initiative to produce a Point-of-Care information system for the anesthesiologist’s use within the operating room. This system is available on the patient’s monitor (or automated record-keeper), and offers quick access to reliable and current information, as well as various emergency protocols. We believe that such a system may contribute significantly to patient safety in the operating room. In order to examine anesthesiologists’ views on the need for such Point-of-Care information system, we circulated a questionnaire during the 2001 annual meeting of the ESA in Gothenburg, Sweden. The questionnaire was answered by 329 anesthesiologists, mostly qualified specialists from western Europe. Of the responders, 46% admitted that they experienced lack of knowledge about drugs, medical conditions and/or specific anesthetic considerations at least once a week. In response to another question, 39% admitted that in the past they have committed medical errors during anesthesia due to lack of medical information that can be found in a handbook. Of all responders, 88% thought that having Point-of-Care information in the OR was either important or very important. We believe that the results of the Gothenburg questionnaire support our notion that there is a relatively high incidence of cases in which anesthesiologists lack sufficient knowledge that might be vital for error prevention. Problems resulting from this can be considered a “system failure” rather than an individual one.

The project of a Point-of-Care information system for anesthesiologists, called On-Line Electronic Help (OLEH), was presented to the Board of the ESA and approved in 1999. The contents of the OLEH were thereafter prepared by members of the Department of Anesthesiology and Intensive Care, Sheba Medical Center, Tel Aviv University, Israel. Information from a variety of sources was included in the OLEH, with the major criterion being the potential usefulness of the information to the anesthesiologist, in real-time. The OLEH draft was submitted to the Scientific Sub-Committees of the ESA for a review process, in order to ensure the overall quality of the information and its suitability for anesthesiologists from many different backgrounds. In addition, the editor and the ESA’s Scientific Committee are in charge of producing periodical updates.

The OLEH contains sections on drugs, preoperative considerations, surgical subspecialties, fluids and electrolytes, transfusion medicine, intraoperative complications, regional anesthesia, postoperative pain management, and emergency algorithms (CPR, malignant hyperthermia, and difficult intubation). In addition, the software includes a section in which each department can add local guidelines, protocols, or material in other languages. The OLEH was prepared in a browser format and was initially designed to fit a windows format that can be opened within the monitor’s screen. The navigation to the required information does not exceed 4 steps, and is facilitated by close to 3000 internal hyperlinks.

On April 6, 2002, Philips Medical Systems and the ESA announced an agreement that makes Philips the exclusive founding sponsor of the ESA’s OLEH. As a result of its support for the project, Philips will also provide access to the package from monitors used in the operating room, when OLEH becomes available later this year.

In summary, OLEH addresses the need for quick access to authoritative and up-to-date information in the OR. Along with information compiled by experienced clinicians for the peri-operative management of patients, the system also provides emergency protocols to facilitate anesthesiologists’ performance in a variety of situations. As anesthesiologists, we have often been recognized for our efforts in improving patient safety, and we should be continuously looking for what can be done to further reduce preventable patient harm in anesthesia.2,3 High reliability organizations are characterized by a strong culture of safety, and by the development of systems that guard against the fallibility of humans working with complex processes.2 It is all too true that, “If we truly want safer care, we will have to design safer systems.”4 The ESA is proud of its contribution to the on-going effort to improve patient safety by providing this innovative Point-of-Care information system.

Dr. Perel, Editor of the OLEH Project, is Professor and Chair of the Department of Anesthesiology and Intensive Care, Sheba Medical Center, Tel Aviv University, Israel, 52621. Address comments to him at [email protected]

Editor’s Note: Dr. Perel does not have any financial, consulting or commercial relationship to Phillips Medical Systems. His hospital has received an educational grant from the ESA for the preparation of the OLEH.


  1. Yamamoto Y, et al. The statistical analysis of quality improvement system at Hamamatsu University School of Medicine for 5 years. In: Ikeda K, Doi M, Kazema T, eds. State-of-the-Art Technology in Anesthesia and Intensive Care, eds. Amsterdam: Elsevier, 1998.
  2. Small SD. Reframing the question of human error: Tools to navigate the next era in anesthesia safety. ASA Refresher Course Lectures, Vol 29, 2001.
  3. Rall M et al. Patient safety and errors in medicine: Development, prevention and analyses of incidents. Anasthesiol Intensivmed Notfallmed Schmerzther 2001;36:321-30.
  4. Berwick DM, Leape LL. Reducing errors in medicine. BMJ 1999;319:136-7.