Dr. Jeffrey Cooper, professor of Anaesthesia at Harvard Medical School, delivered a poignant keynote lecture entitled, “Anesthesiology’s Leadership in Patient Safety: Lessons from the Past and Planning for the Future,” at the first International Forum on Perioperative Quality and Safety on October 20, 2017. He foreshadowed a challenge he would later ask the audience to contemplate: “The One Thing,”a actually one new thing, that we as professionals can do to improve anesthesia patient safety through research and action.
Dr. Cooper alluded to studies suggesting that anesthesia safety has improved throughout the years. Specifically, anesthesia related mortality was approximately 1/10,000 for healthy patients 30–40 years ago.1 Recently, investigators suggest mortality has improved to 1/200,000 for healthy patients in developed nations.1 While these numbers serve as benchmarks for success, they clearly do not tell the whole story or complete the action that is required to meet the APSF goal and vision that “no patient shall be harmed by anesthesia.” Dr. Cooper referred to last year’s EC Pierce lecture, given by Dr. Alexander Hannenberg, entitled “Safety Beyond Borders: Different But The Same,” where Dr. Hannenberg suggested that surgical/anesthesia related mortality in developing nations in Africa remains alarmingly high (100–1000 fold greater than developed nations).2 Therefore, more work is required and more leadership is needed to improve surgical/anesthesia related mortality worldwide.
A safety pioneer in his own right, Jeff Cooper described his own experience with patient harm caused by a defect deliberately introduced into an anesthesia machine during a teaching session he was observing many years ago. He explained how his failure to speak up against an authority gradient was an example of how accidents occur. That formative event probably helped to inspire his seminal work in illuminating how human factors play a significant role in the perpetuation and magnification of medical errors resulting in patient adverse events.3 Inspired by his own experiences coupled with observations of others, Dr. Cooper, working with the late Dr. Richard J. Kitz, to whom he dedicated his presentation, and Dr. Ellison C. (Jeep) Pierce, Jr., MD, organized the first ever meeting on anesthesia patient safety entitled the “International Symposium on Preventable Anesthesia Morbidity and Mortality,” in Boston, MA, in 1984. Following this iconic meeting among 50 invited international safety leader participants, Jeep Pierce, ASA president in 1984, called for the development of an independent foundation dedicated to improving anesthesia patient safety with the mission noted above. It was Dr. Cooper who suggested that it should be called what it is today, the “Anesthesia Patient Safety Foundation, APSF.” So, a new safety era began in 1985, where the APSF established the following goals:4
- Sponsor research that facilitates a clearer understanding of preventable anesthetic injuries.
- Encourage educational programs that may aid in reducing preventable anesthetic injuries.
- Promote national and international dialogue and exchange of ideas with regard to the causes and prevention of anesthetic injuries.
- Establish an APSF Newsletter to be given to all anesthesia professionals free of charge that informs them of anesthesia patient safety-related topics (which has now grown to a circulation of over 122,000 and is expected to grow internationally!).
With the continuous flow of energetic anesthesia safety leader volunteers and multidisciplinary organizational support, the APSF has been able to educate anesthesia professionals on such safety issues as: setting critical audible anesthesia machine alarms, recognizing the dangerous by-products and flammable reactions that can occur with volatile anesthetics and CO2 absorbents, prevention of operating room fires, monitoring to prevent opioid induced ventilator impairment (OIVI), the hazards of the beach chair position, management of perioperative visual loss, and the usefulness of simulation and emergency manuals (to name just a few).
With the rise of the anesthesia safety movement and the creation and promulgation of the APSF, Dr. Cooper reflected on his original question as to whether anesthesia has become safer for patients over the last 30 years. He provided data on medical malpractice premiums that suggest that, during 1987–2015, premiums have dropped by a magnitude of 5-fold. However, Dr. Cooper cautioned the audience that new threats such as production pressure, provider fatigue, intra- and inter-disciplinary miscommunication, and provider disruptive behaviors all challenge the preservation of patient safety gains especially because, given the perceived safety, surgery is more likely to be undertaken on sicker patients and for more complex procedures. Emergency manuals, perioperative safety checklists, and structured handoffs may provide safety buffers for these emerging threats.
Dr. Cooper concluded his lecture by suggesting the “One Thing” that has been almost entirely ignored in perioperative patient safety: the relationship between surgeons and anesthesia professionals, which is a critical dyad of the perioperative team. He suggested that all anesthesia providers should seek out their surgical colleagues to engage in conversations to better understand each other’s perspectives and concerns. Doing so, he believes, will not only advance patient safety but increase satisfaction and meaning of the work for those who provide perioperative care.
Dr. Cooper ended with a video of Dr. Pierce’s 1995 Rovenstine Lecture at the ASA Annual meeting, in which he said, “My friends and colleagues, our efforts to improve the safety of anesthesia have merely begun. Significant challenges await us, perhaps more so in the coming years than in the past four decades that I have had the pleasure and privilege to describe to you. But we must not retreat; we must not lose our collective resolve. Patient safety is truly the framework of modern anesthetic practice, and we must redouble efforts to keep it strong and growing.”5 The echoed encouragement from Dr. Pierce, inspired Dr. Cooper to urge audience members once again to find their “One Thing” that will improve the safety of our patients requiring anesthesia in the present and future.
Dr. Greenberg is presently Editor-in-Chief of the APSF Newsletter and Vice Chairperson of Education in the Department of Anesthesiology, Critical Care and Pain Medicine at NorthShore University HealthSystem in Evanston, IL. Dr. Greenberg is also Clinical Associate Professor in the Department of Anesthesia/Critical Care at the University of Chicago.
He has no disclosures pertaining to this report.
a.“The One Thing,” is a well-known quote provided by the character “Curly, played by Jack Palance” in the 1991 hit move, City Slickers.
- Lagasse R. Anesthesia safety: model or myth?: a review of the published literature and analysis of current original data. Anesthesiology 2002;97:1609–17.
- “Pierce lecturer addresses challenges to patient safety in developing world.” (2016, October 23). Retrieved from: http://asa-365.ascendeventmedia.com/anesthesiology-2016-daily/pierce-lecturer-addresses-challenges-to-patient-safety-in-developing-world.
- Cooper J, Newbower RS, Long CD, et al. Preventable anesthesia mishaps: a study of human factors. Anesthesiology 1978;49:399–406.
- Eichorn JH. The APSF at 25: Pioneering success in safety, but challenges remain. 25th anniversary provokes reflection, anticipation. APSF Newsletter 2010;25:21–44.
- Ellison C. Pierce. The 34th Rovenstine lecture: 40 years behind the mask: safety revisited. Anesthesiology 1996;84: 965–975.