Issues in patient safety must he addressed from many different aspects. Among these are the questions of physician training and qualifications, equipment quality and quantity, hospital awareness of the safety issue, appropriate staffing, quality assurance, and ongoing review of standards as well as performance.
In the state of New Jersey, this matter has been addressed by the N.J. State Society of Anesthesiologists through its Executive Committee with ultimate ratification by the membership at large.
Early in the course of these efforts, attempts were made to raise the level of awareness of the state’s anesthesiologists by frequent reminders of the urgency of the patient safety issue. There were many articles in the state society newsletter addressing safety, liability concerns, and the frequency of patient injury.
The N.J. State Medical Society sponsored professional liability insurance company addressed the issue of anesthetic incidents by surveying the patterns of cases reported. This led to a study of anesthetic injuries presented as a scientific exhibit at the NISSA Annual Meeting which was then modified, expanded and presented again at the ASA Annual Meeting. The insurance carrier also published a specialty-specific newsletter for all anesthesiologists addressing the most commonly reported anesthetic injuries and noting changes in patterns over the course of several years.
The NISSA also took the forefront in advising the State Board of Medical Examiners on matters of staffing of anesthesia personnel and of the sphere of activity considered appropriate for nurse anesthetists. The Society also came out with recommendations for supervision of CRNNs and ratios that were felt proper.
The question of anesthesia equipment was addressed by the society and monitoring issues were brought to the attention of the office of the State Health Commissioner. These discussions and negotiations were largely the work of Dr. Ervin Moss, who convinced the state agency responsible for inspecting hospitals of the importance of up-to-date anesthesia equipment with appropriate safety features. After many long and difficult sessions, state authorities now seem to be aware that hospital inspectors need to be trained to evaluate the level of adequacy and safety of anesthesia equipment rather than the mundane details formerly addressed. One hospital was previously cited for dust on an anesthesia machine shelf when no mention was made of safety interlocks or disconnected alarms! Fortunately, this situation seems to be changing.
State standards are also being instituted for anesthesia personnel and staffing. These include the requirement that, by 1989, department directors be board certified and that anesthesiologists supervising non-physician personnel be in a ratio of no more than 2:1 and not performing services for another patient of his/her own while supervising.
A draft of the recommendations for anesthesia equipment addresses safety features for the equipment which include the following:
1. Diameter index safety systems (DISS) are to be used on all anesthesia machines to prevent interchangeability of oxygen and other gases (especially nitrous oxide.)
2. AD hose-s and adapters are to be color coded. 3. Cylinders for emergency use are to be
attached to all anesthesia machines and are to be pin-indexed. Single washers shall be used.
4. An oxygen failure protection devise (“fail-safe” system) is to be used to announce failure and will, at lowered levels of oxygen pressure, discontinue the flow of nitrous oxide.
5. An oxygen concentration monitor will be activated within the breathing circuit displaying the inspired oxygen level.
6. A vaporizer exclusion system is to be used to assure that only one volatile anesthetic can be used at one time.
These proposed standards have been approved by the Executive Committee of the NISSA and we expect them to be approved by the State Department of Health with implementation in the near future. Such standards, it is believed, will go a long way in helping retire obsolete and unsafe anesthesia machines which represent such a hazard to patients. These hazards are well appreciated by all anesthesiologists but, in too many cases, the funds for upgrading or replacing such machines are not made available. With the application of these reasonable, minimal equipment standards, we believe we can help save lives and prevent patient injuries.
Dr. Hatchfield, formerly of the NJSSA Executive Committee, now practices in Rhineback, N.Y.