Improving Perioperative Patient Safety: A Matter of Priorities, Collaboration, and Advocacy

Mark A. Warner, MD
Dr. Mark Warner, APSF President

Dr. Mark Warner, APSF President

We live in a world of competing priorities when we care for patients. On any given day, we are cajoled, pushed, and even prodded to provide cost-effective, efficient, highly productive patient care. In many environments, the faster and cheaper we provide anesthesia services, the more kudos we receive from our health care leaders. In far too many instances, there is less emphasis on providing safe care because it is assumed that the care we provide will be safe. While efficiency and safe care can be balanced effectively, we know that far too many patients are harmed during their perioperative care, including during their anesthetics, when the pressure to speed patient throughput is emphasized more than safety.

When we are patients, our priorities often might not match those of the colleagues who are taking care of us. In general, as patients we tend to place high value on perioperative safety. Yes, we want our care to be efficient and our surgical outcomes to be excellent, but getting through the perioperative period with no complications or unexpected problems is also an important patient priority.

The Importance of Setting Anesthesia Patient Safety Priorities

As a foundation dedicated to patient safety, the Anesthesia Patient Safety Foundation (APSF) strives to help our patients achieve their priority of receiving safe intraoperative and perioperative care. In the past decade, training requirements for many new anesthesia professionals and breadths of clinical practices in the U.S. have been extended into the full spectrum of perioperative care, evolving towards those in a number of other nations. These changes in the U.S., along with a growing emphasis on enhanced recovery pathways, have prompted opportunities to increase patient safety initiatives throughout the perioperative period.

As a consequence, anesthesia patient safety is now a remarkably broad topic, ranging from pulmonary aspiration on induction of anesthesia through postoperative issues such as opioid-induced respiratory arrest, prolonged cognitive impairment, and failure-to-rescue patients during acute physiologic deterioration. APSF has embraced this expansion of the scope of anesthesia patient safety.

Each year, the APSF committees and Board of Directors review existing and emerging perioperative patient safety issues and develop a list of the foundation’s highest priority issues. Table 1 provides a list of these priorities and actions taken by the APSF to promote and improve them during the past 5 years. Many of these issues need long-term commitment of resources and advocacy to obtain patient safety improvements.

Table 1: APSF’s 2021 Perioperative Patient Safety Priorities and Ongoing Activities.

The following list contains our top 10 priorities and the associated activities.
The summary of activities is not exhaustive.

1. Preventing, detecting, and mitigating clinical deterioration in the perioperative period

    1. Early warning systems in all perioperative patients
    2. Monitoring for patient deterioration
      1. Postoperative continuous monitoring on the hospital floor
      2. Opioid-induced ventilatory impairment and monitoring
      3. Early sepsis
    3. Early recognition and response to decompensating patient
APSF Activities:

  • The 2019 APSF Stoelting Conference was dedicated to this topic
  • This topic has been highlighted in 2020 APSF Newsletter issues and APSF-sponsored panels and presentations
  • APSF is collaborating with American Society of Anesthesiologists (ASA) and other subspecialty organizations to address specific issues related to this topic
  • APSF will support prototype development for several models that may reduce failure-to-rescue
  • APSF has supported 2 research grants on this issue in the past 5 years

2. Safety in non-operating room locations such as endoscopy and interventional radiology suites

APSF Activities:

  • APSF has addressed aspects of this issue recently in APSF Newsletter articles (e.g., June 2020)
  • APSF has supported 3 research grants on this issue in the past 5 years

3. Culture of safety: the importance of teamwork and promoting collegial personnel interactions to support patient safety

APSF Activities:

  • APSF addressed this issue in its 2017 ASA Annual Meeting workshop, as well as in APSF Newsletter articles and presentations
  • The 2019 Pierce Lecture by Jeff Cooper, Ph.D. highlighted this issue; his remarks were published in February 2020 APSF Newsletter
  • APSF has supported 1 research grant on this issue in the past 5 years

4. Medication safety

    1. Drug effects
    2. Labeling issues
    3. Shortages
    4. Technology issues (e.g., barcoding, RFID)
    5. Processes for avoiding and detecting errors
APSF Activities:

  • The 2018 APSF Stoelting Conference was dedicated to this topic
  • APSF presented panels at the 2019 ASA and New York State Society of Anesthesiologists’ annual meetings
  • APSF will co-host a consensus workgroup on drug labeling in 2021 with the Institute for Safe Medication Practices
  • Multiple APSF Newsletter articles have been published on this issue in 2020

5. Perioperative delirium, cognitive dysfunction, and brain health

APSF Activities:

  • The APSF supports this ASA-American Association of Retired Persons initiative
  • This issue is addressed in our October 2020 APSF Newsletter
  • APSF has supported 3 research grants on this issue in the past 5 years

6. Hospital-acquired infections and environmental microbial contamination and transmission

APSF Activities:

7. Patient-related communication issues, handoffs, and transitions of care

APSF Activities:

8. Airway management difficulties, skills, and equipment

APSF Activities:

  • Several APSF articles have addressed this issue in recent APSF Newsletter articles
  • APSF has supported 3 research grants on this issue in the past 5 years

9. Anesthesia professionals and burnout

APSF Activities:

10. Distractions in procedural areas

APSF Activities:

We then use this list to drive our website and Newsletter content, research funding, and educational panels and forums (e.g., the annual Stoelting Conferences). While several of these priorities are specific to intraoperative anesthesia care (e.g., distractions in procedural areas), 8 of the 10 have scopes that extend throughout the full perioperative spectrum of issues. A very pertinent, timely example is hospital-acquired infections and environmental microbial contamination and transmission (e.g., COVID infection and its many ramifications on intraoperative and perioperative care and provider safety). The APSF has addressed pandemic-related issues extensively in 2020 ( More than 600,000 individuals from every country worldwide have accessed our website and Newsletter for important COVID patient and provider safety information during the pandemic.

Prioritization matters when there are limited resources, expertise, and time. This is when teamwork becomes so vitally important. No one organization; no one health system; and no one professional society can have a positive impact on all of the important perioperative patient safety issues. It takes a team, with each member making its own unique contributions in collaboration with others. That is why APSF and health care leaders from around the world continually discuss perioperative patient safety issues and how we can work together to solve these crucial, prioritized issues that are important to all of us. That includes every anesthesia professional who provides patient care.

What can you and the groups in which you have influence do to improve perioperative patient safety? It is incumbent on each of us to ask what we can do personally and together within the specialty and outside of it to make a difference. It includes reaching beyond our usual comfort zones of clinical practice and seeking opportunities that involve working with others who are involved in the perioperative care spectrum. For APSF specifically, it has included developing our social media capabilities such as Facebook, Twitter, and Instagram to reach anesthesia professionals around the world who otherwise would not be aware of our patient safety priorities and initiatives. We have a remarkably successful podcast initiative ( that provides important anesthesia patient safety updates on a variety of topics, including our patient safety priorities.

Professional Wellness: An Important New APSF Priority

A growing number of publications report that it is important for our anesthesia colleagues to be safe because impaired colleagues increase the risk of patient harm. Patient harm associated with impaired anesthesia professionals is a growing issue as stresses and personal health risks in anesthesia professionals have risen. The stresses associated with the current COVID pandemic provide a good example. For example, the intubateCOVID registry, partially supported by APSF, has described in July 2020 that there is a 3.1% risk of new lab-confirmed COVID-19 and an 8.4% risk of new symptoms requiring self-isolation or hospitalization in health care workers who intubated patients with suspected or confirmed COVID. (

The APSF has recognized the need to integrate anesthesia professional wellness into our foundation’s vision. Our vision previously was “that no patient shall be harmed by anesthesia.” It now reads “that no one shall be harmed by anesthesia care.” This latter version adds the well-being of anesthesia colleagues to our vision and extends our role beyond traditional intraoperative patient safety.

The 2021 Stoelting Consensus Conference on September 8th and 9th will focus specifically on anesthesia professional wellness and its potential negative impact on patient safety. This conference will discuss potential interventions to reduce patient and provider harm and provide recommendations to implement the best of these interventions.

Prioritizing Anesthesia Patient Safety: It Takes Everyone

The APSF is fortunate to work closely with partners around the world to advocate for anesthesia patient safety. While the foundation can stimulate discussions, promote the generation of new knowledge related to perioperative safety priority issues, and develop consensus recommendations, it takes everyone working together to advocate for anesthesia patient safety. We sincerely appreciate the outstanding efforts and contributions of partners such as the World Federation of Societies of Anaesthesiologists (WFSA); regional societies such as the European Society of Anesthesiologists, Confederation of Latin American Societies of Anaesthesiology, and others; and many national anesthesia societies that have been major leaders in anesthesia patient safety.

Examples from the past several years of these collaborations include our work with the national societies of anesthesiology in Japan, China, Brazil, Portugal, Spain, France, Columbia, Mexico, and other countries to develop translated issues of the APSF Newsletter. The Newsletter is now available in five translated languages, allowing us to reach an expanded proportion of the world’s anesthesia professionals. APSF has supported patient safety education research projects with the WFSA and the Patient Safety Movement Foundation. These education projects will lead to improved subspecialty training in low resources countries and the development and implementation of anesthesia-specific patient safety curricula for training programs and continuing education of anesthesia professionals. We’ve collaborated on clinical patient safety research grants with the Foundation for Anesthesia Education and Research and the Orthopaedic Research and Education Foundation to generate the next generation of anesthesia patient safety clinician scientists.

It is the union of these groups and their collaborative contributions that make big impacts. Please support their efforts. However, and most importantly, please advocate personally for patient safety every day and in every way. It is the right thing to do for our patients and our combined personal advocacy has the biggest positive impact of all on anesthesia patient safety.


Dr. Mark Warner is currently president of the APSF and the Annenberg Professor of Anesthesiology, Mayo Clinic, Rochester, MN.

The author has no conflicts of interest.