Mandatory Safety Reporting Anesthesia Safety – By Any Means Necessary?

George Mychaskiw II, DO

Letter to the Editor:

Very few can deny that the practice of anesthesia is safer today than it was twenty years ago, and indeed, safer than at any time in history. New monitoring technologies, safer, more easily used drugs and increased knowledge of physiology are just a few of the reasons for this accomplishment. When asked, however, “is anesthesia as safe as it can be?”, the answer must be no. Although it is a tired and frequently untrue adage that anesthesia and aviation are similar, safety evaluation and improvement are very similar in the two fields. Consider the numbers. The risk of death from anesthesia is estimated in the range of 1 in 10,0001 to 1 in 200,000.2 The chance of dying in a plane crash on a U.S. carrier is about 1 in 10,000,000.3 By even the most conservative (and unlikely) estimate, this makes undergoing anesthesia about 20 times more dangerous than flying. Most would say that this disparity is explained by the fact that aviation entails interaction with well-defined and maintained mechanical systems, while anesthesia involves unpredictable biological systems compromised by disease and subjected to surgical trauma. No doubt this is true, but only partially. Aviation also relies on biological systems (i.e. pilots, mechanics) to accomplish its goals in equipment which must encounter obstacles of weather while under (again, human) pressure to generate as much revenue as possible. By applying lessons from aviation, can anesthesia be made safer? In anesthesia, as in aviation, most accidents result from human error. Unfortunately, the mechanical systems of anesthesia machines and aircraft are far less fallible than the people entrusted to operate them. In anesthesia, we are just beginning to address the human factor of anesthesia safety. While airlines have studied crew interaction for many years, we are in our infancy in looking at these problems. To a large degree, we in anesthesia are hindered in our inability to identify behaviors and ergonomic factors, which may lead to accidents. The ASA Closed Claims Studies are important, but they obviously do not account for all anesthetic misadventures. Far, far more incidents and accidents occur which never reach the courtroom, but which we could learn from, if the information was available. Experience is not the best teacher, if it cannot be used. If we are truly committed to patient safety, then we cannot avoid the fact that most incidents are unreported. Thus, problems, which may be addressed earlier, must cause significant morbidity before they are noticed by the anesthesia safety community. Distasteful as it may seem, mandatory reporting of all anesthesia incidents, regardless of patient outcome, in an accessible database is necessary if we are to seriously improve anesthesia safety. A quasi-governmental agency, such as the National Transportation Safety Board (the “National Anesthesia Safety Board”?) should be created to investigate any incident which results in morbidity. Additionally, recording of voice, video and machine/hemodynamic data as a universal standard would quickly explain many anesthesia misadventures, just as the “black boxes” have helped to determine the cause of many airline crashes. Obviously, the outcry against such a proposal would be tremendous. In our litigious world, opening a floodgate of lawsuits is a possibility, which should be considered, but should this take precedence over patient safety? The NTSB makes conclusions about air crashes in the interest of preventing them in the future, without regard for the legal ramifications. Should this not be our approach? Additionally, if an anesthetic accident occurs despite a practitioner adhering to the standard of care, the conclusions of a safety board and hard data from “black boxes” should exonerate, rather than indict the practitioner. Data generated by mandatory reporting, safety board investigation and even “black boxes” would give the anesthesia community a true picture of what is the true incidence and scope of anesthesia problems. Armed with this data, we could study and modify our techniques, behaviors, and equipment and further increase anesthesia safety. Despite concerns about cost, litigation and privacy, we can exponentially improve anesthesia safety – if we have the courage to do so.

George Mychaskiw II, DO Associate Professor of Anesthesiology, Surgery, and Physiology Director, Cardiac Anesthesiology University of Mississippi School of Medicine/ Medical Center, Jackson, MS

References 1. Keenan RL. What is known about anesthesia outcome. In Eichhorn JH (ed): Improving Anesthesia Outcome: Problems in Anesthesia 5:179, 1991. 2. Lunn JN, Devlin HB. Lessons from the confidential inquiry into perioperative deaths in three NHS regions. Lancet 2:1384, 1987. 3. Annual review of aircraft accident data U.S. air carrier operations, calendar year 1996. NTSB document ARC/99-01.