The history and development of the anesthesia patient safety “movement” as well as its impact on practice habits and patient outcome were the topics of the two keynote memorial lectures of the 1995 edition of the American Society of Anesthesiologists’ Annual Meeting held in Atlanta, October 21-25.
E.C. “Jeep” Pierce, Jr., M.D., APSF President, delivered the Rovenstine [apologies for previous misspelling] Lecture entitled “Forty Years Behind the Mask: Safety Revisited.” E.S. “Rick” Siker, M.D., APSF Executive Director, delivered the Wood Library Museum-sponsored Lewis H. Wright, M.D. lecture entitled “Anesthesia Safety – An Evolution.”
Dr. Pierce described practice conditions when he started his training in 1954, including intraoperative monitoring consisting of counting heart and respiratory rates, inspecting pupils, taking an occasional blood pressure, and putting a stethoscope on the precordiums of children. He recalled the introduction in the U.S. of the copper kettle and the many arrests caused by accidental overdoses of ether and also the indictment of neuromuscular blockers that followed the Beecher and Todd study of surgical deaths. In the 1950s, one study suggested 3.7 anesthetic deaths per 10,000 patients.
Dr. Pierce related an overview of studies and events in the evolution of concerns about anesthesia safety, emphasizing the 1982 “20/20” extremely dramatic television program about the dangers of anesthetic complications and the shortage of anesthesiologists. Dr. Pierce related how events and his initiating efforts meshed together to help lead to, first, the creation of the ASA Patient Safety Committee, then the 1984 International Symposium on Preventable Anesthesia Mortality and Morbidity, and, finally, the Anesthesia Patient Safety Foundation itself in 1985.
The APSF philosophy, function, and accomplishments (particularly this Newsletter and the multitude of funded research projects) were outlined as well as the general evidence from recent years that patients receiving anesthesia care are, in fact, much safer now (mortality less than 0.05 per 10,000 patients) compared to early in Dr. Pierce’s career. He cited the remarkable decrease in malpractice insurance relativity ratings for anesthesiologists and their lowered insurance premiums (a calculated savings of up to as much as $300 million annually compared to unchecked increases if nothing had changed) as indirect proof of the improvements in patient safety.
Dr. Pierce also outlined current safety efforts, particularly the emphasis on human factors and performance research and anesthesia simulators. He concluded by noting that patient safety is not a fad and the problems are not solved. Specifically, he cited the potential threat to anesthesia patient safety by severe cost-cutting measures encouraged or even forced by the advent of managed care systems, as outlined in the major analysis offered by Dr. J.S. Gravenstein in the last issue of this Newsletter. Dr. Pierce urged no retreat and called for a redoubling of efforts to keep the patient safety “movement” strong and growing.
Dr. Siker provided an historical perspective of anesthesia safety. He noted the widely differing definitions of what constitutes anesthesia mortality or morbidity and how difficult cohesive research and comparisons are as a result. In the decade following the introduction of ether in the 1840s, John Snow explored the use of ether and reported six deaths in 80 cases. Likewise, he kept a log of outcome from chloroform anesthetics and reported 49 deaths in its first ten years of use. The debate on the relative safety of the two anesthetics raged for decades. Harvey Cushing as a medical student was called upon to administer ether and a patient died, leading to the creation of the first anesthesia records so that he might better understand what was happening to his patients. In the mid part of this century, serious attention to anesthesia complications and morbidity was devoted by the likes of Waters, Rovenstine, MacIntosh, and Mushin. Also, the American Board of Anesthesiology contributed significantly to improved safety after its birth in 1941 by actually sending examiners to candidates’ hospitals to give on-site practical examinations, thereby raising the skill level of certified anesthesiologists dramatically.
Dr. Siker detailed his own role in the early investigation of halothane’s clinical application and his increased motivation to promote its adoption after hearing of a 1958 cyclopropane explosion that killed many people as it blew out the side of a building. Dr. Siker concluded by noting that even with the recent dramatic improvements in anesthesia patient safety, it is still statistically safer to fly on a commercial airplane, making it up to all anesthesia practitioners to continue to strive to make anesthesia care yet even safer.