Circulation 81,489 • Volume 22, No. 1 • Spring 2007   Issue PDF

Looking Back: Doctor Pierce Reflects

Ellison C. Pierce, Jr., MD

(An excerpt from the 1995 Emery A. Rovenstine Lecture)

On Thursday, April 22, 1982, there appeared on ABC television a segment of the program 20/20 entitled, “The Deep Sleep, 6,000 Will Die or Suffer Brain Damage.” The announcer opened the program, “If you are going to go into anesthesia, you are going on a long trip and you should not do it, if you can avoid it in any way. General anesthesia is safe most of the time, but there are dangers from human error, carelessness and a critical shortage of anesthesiologists. This year, 6,000 patients will die or suffer brain damage.” Following scenes of patients who had anesthesia mishaps, the program went on to say, “The people you have just seen are tragic victims of a danger they never knew existed—mistakes in administering anesthesia.” In another example shown on the program a patient was left in a coma following the anesthesiologist’s error in turning off oxygen rather than nitrous oxide at the end of an anesthetic. Later in the program, the following dialog ensues. An unidentified spokesperson advises Tom Jerriel, one of the hosts, that, “There is a hospital in New York City where there are two anesthesia people covering five operating rooms.” Jerriel is incredulous, and asks, “How do they do it?” The spokesperson replies, “Well, they run quickly and pray a lot.”

The 20/20 program was a watershed for anesthesia patient safety endeavors. At the time, I was ASA first vice president and decided to establish a new ASA committee, the Committee on Patient Safety and Risk Management. Howard Zauder was the first chairman. The ASA had, of course, been involved in quality assurance for some time with its Committee on Peer Review, but never before had the concept of patient safety been so specifically addressed by our specialty society. Among its first endeavors the Committee developed a series of patient safety videotapes. . . with me as executive producer. In 1984, Cooper, Richard Kitz, and I hosted the first International Symposium on Preventable Anesthesia Mortality and Morbidity (ISPAMM), held in Boston. Some 50 anesthesiologists from the United States, Australia, Great Britain, South Africa, and Belgium attended. Debate was loud and strong; controversy among the nations was extensive, especially considering use of monitoring equipment. Perhaps the area of greatest agreement was in the definitions of outcome, morbidity, and mortality. That international meeting has now been held every 2 years since.

The Anesthesia Patient Safety Foundation (APSF) was established as an outcome of the Boston meeting. Considerations of attaching a safety society to other entities, such as the World Health Organization, were rapidly abandoned because of the probabilities that international controversy would prevent effective actions.

Dr. Pierce is currently retired as chairman emeritus of the Department of Anaesthesia at Deaconess Hospital and is the founder and former executive director of the APSF.