Circulation 118,032 • Volume 29, No. 3 • February 2015   Issue PDF

President’s Report Highlights Accomplishments of 2014

Robert K. Stoelting, MD

Robert K. Stoelting, MD APSF President

As president of the Anesthesia Patient Safety Foundation (APSF), it is my privilege to report annually on the activities of the foundation during the past calendar year. As in my previous annual reports, I believe it is important to recognize that APSF, as an advocacy group, does not write standards. Recommendations developed and promulgated by APSF are intended to assist professionals who are responsible for making health care decisions. Recommendations promulgated by APSF focus on minimizing the risk to individual patients for rare adverse events rather than necessarily on practices that balance all aspects of population health quality and cost. APSF does not intend for these recommendations to be standards, guidelines, or clinical requirements, nor does application of these recommendations guarantee any specific outcome. Furthermore, these recommendations may be adopted, modified, or rejected according to clinical needs and restraints. APSF recognizes that these recommendations are subject to revision as warranted by the evolution of medical knowledge, technology, and practice.

A highlight of the annual meeting of the American Society of Anesthesiologists in New Orleans on October 11, 2014, was the Ellison C. Pierce, Jr., MD, Patient Safety Memorial lecture delivered by David M. Gaba, MD. Dr. Gaba’s topic was Competence and Teamwork Are Not Enough: The Value of Cognitive Aids. Dr. Gaba’s lecture is posted online on ASA’s Education Center

This named lectureship continues to be part of the annual ASA meeting, thus providing sustained recognition for the vision and contributions to anesthesia patient safety made by Dr. Pierce as the founding president of APSF.

The annual APSF Board of Directors Workshop, entitled
Competence and Teamwork are Not Enough: Implementing Emergency Manuals and Checklists, immediately followed the Pierce Lecture and was moderated by APSF Executive Vice President Jeffrey B. Cooper, PhD.

Educational DVDs

In early 2014, APSF announced the availability of complimentary copies of the following educational DVDs (visit the APSF website for details,

  • Opioid-Induced Ventilatory Impairment (OIVI): Time for a Change in the Monitoring Strategy for Postoperative PCA Patients (Executive Summary, 7 minutes)
  • Perioperative Visual Loss (POVL): Risk Factors and Evolving Management Strategies (Executive Summary 10 minutes)
  • APSF Presents Simulated Informed Consent Scenarios for Patients at Risk for Perioperative Visual Loss (POVL) (18 minutes).

The simulated informed consent scenarios are based on the conclusions of the September 11, 2012, APSF-sponsored multispecialty conference that “the remote risk of blindness should be part of the informed consent process” for patients at risk for POVL.

Residual Muscle Relaxant-Induced Weakness in the Postoperative Period: Is It a Patient Safety Issue?

APSF believes that residual neuromuscular blocking drug-induced muscle weakness in the postoperative period is a patient safety hazard that could be addressed by objective monitoring of the effects of neuromuscular blocking drugs along with traditional subjective observations.

The peer review literature supports the conclusion that residual neuromuscular blocking drug-induced muscle weakness is more common in the postoperative period than often appreciated and this weakness may contribute to adverse patient events (delayed discharge from the PACU, need for tracheal reintubation, impaired oxygenation and ventilation [may be erroneously attributed to opioids], aspiration, pneumonia).

Furthermore, the peer review literature supports the belief that addition of objective monitoring of the effects of neuromuscular blocking drugs to the traditional subjective observations will reduce the likelihood of unrecognized and clinically significant drug-induced muscle weakness in the postoperative period with resulting improved patient safety.

For these reasons, APSF is requesting that the American Society of Anesthesiologists (ASA) via its Committee on Standards and Practice Parameters (CSPP) consider “residual neuromuscular blocking drug-induced muscle weakness in the postoperative period” as a high priority for creation of a “neuromuscular blockade document” to present to the October 2015 ASA House of Delegates.

Anesthesia Professionals and the Use of Advanced Medical Technologies: Recommendations for Education, Training, and Documentation

APSF believes that anesthesia professionals should demonstrate competence to use advanced medical technology before applying this technology to patient care. Anesthesia professionals have not generally been required to demonstrate their competence to use anesthesia technology to care for patients. In contrast, mandatory user training and/or demonstration of competence are currently required for clinicians who use devices including lasers, radiation emitting devices (fluoroscopy), some technology-based surgical procedures (carotid stents), and point-of-care laboratory devices. Demonstrating competency to use medical devices is consistent with safe patient care.

In October 2014, the ASA House of Delegates approved a recommendation to “endorse the key safety issues of training and education” as developed by the APSF Committee on Technology and approved by the ASPF Executive Committee ( Over the next year, the ASA Committee on Equipment and Facilities will work in conjunction with APSF and in consultation with the ASA Committees on Economics, Surgical and Procedural Anesthesia, and Quality Management and Departmental Administration, the Society for Technology in Anesthesia and manufacturers to propose systems that are effective, efficient, economically viable, and accessible, to culminate in a report by the committee to the ASA Board of Directors in October 2015.

Patient Safety and the Perioperative Surgical Home (PSH)

APSF held a consensus conference on this topic on Wednesday, September 3, 2014 (Royal Palms Resort and Spa, Phoenix, AZ). APSF believes that the model envisioned by the PSH will present opportunities for patient safety innovations based on standardization, increased use of protocols, better communication, and teamwork.

Implementing and Using Emergency Manuals and Checklists to Improve Patient Safety

APSF will sponsor an expert’s conference on this topic on Wednesday, September 9, 2015 (Royal Palms Resort and Spa, Phoenix, AZ). The conference will concentrate on the practical aspects of systematically implementing emergency manuals in perioperative settings. Experts on the development and production of emergency manuals will give guidance about key aspects of how to use emergency manuals with a focus on the process of implementation. The critical elements of implementation will be discussed in introductory presentations, followed by a panel discussion and facilitated breakout groups. The session will provide an interactive experience for attendees to learn about “how” to incorporate emergency manuals.

Those interested in attending should contact Dr. Stoelting ([email protected]) for registration details.


The APSF Committee on Scientific Evaluation chaired by Steven K. Howard, MD, received 50 letters of intent and invited 8 investigators to submit completed applications for studies beginning January 1, 2015. In October 2014, the committee recommended funding 3 research awards totaling $450,000.

In addition, APSF supports a Safety Scientist Career Development Award (SSCDA) ($150,000.00 over 2 years) concluding in July 2015. In July 2014, APSF awarded a grant of $200,000 to evaluate the “implementation and performance” of the APSF Pre-induction Patient Safety (PIPS) checklist. Beginning in July 2015, APSF and AQI will co-sponsor a patient safety fellowship.

APSF is the largest private funding source for anesthesia patient safety research in the world. Since the inception of the APSF grant program, 735 grant applications have been received by APSF. When the first grants were funded in 1987, funding for anesthesia patient safety was virtually unknown. Since 1987, APSF has awarded 103 grants for a total of more than $9,446,853. The impact of these research grants is more far-reaching than the absolute number of grants and total dollars, as APSF-sponsored research has led to other investigations and the development of a cadre of anesthesia patient safety investigators.

APSF Newsletter

The APSF Newsletter continues its role as a vehicle for rapid dissemination of anesthesia patient safety information with Robert C. Morell, MD, and Lorri A. Lee, MD, as co-editors. The
APSF Newsletter is provided as a member benefit by the ASA, American Association of Nurse Anesthetists (AANA), American Association of Anesthesiologists Assistants (AAAA), American Society of Anesthesia Technologists and Technicians (ASATT), American Society of PeriAnesthesia Nurses (ASPAN), American Society of Dentist Anesthesiologists (ASDA), American Dental Society of Anesthesia (ASDA) and the American Association of Oral Maxillofacial Surgeons (AAOMS) with a resulting circulation of 118,032. In addition to the electronic version of the
APSF Newsletter, a hardcopy is mailed to all members of the ASA, AANA and AAAA.

The “Question and Answers” and “Dear Sirs” (Safety Information Response System) columns in the APSF Newsletter provide rapid dissemination of safety issues related to anesthesia equipment in response to questions from readers. These columns are coordinated by Drs. A. William Paulsen (chair, APSF Committee on Technology) and Robert C. Morell (co-editor,
APSF Newsletter). The value of industry to anesthesia patient safety is reflected by these columns.


The APSF website design and appearance ( continues under the direction of APSF Executive Vice President George A. Schapiro. The APSF website includes a monthly poll question related to anesthesia patient safety issues. The poll question is coordinated by Timothy N. Harwood, MD, a member of the APSF Committee on Education and Training chaired by Richard C. Prielipp, MD.

Sorin J. Brull, MD, continues as the Patient Safety Section Editor for Anesthesia and Analgesia.

APSF-IARS Safety Panel

Richard C. Prielip, MD, chair, APSF Committee on Education and Training, moderated an APSF-sponsored panel,
Positioning Complications: The “Little Problem” That Keeps Getting Bigger! on May 14 at the 2014 IARS Annual Congress in Montreal. Drs. Charles Hogue, Robert C. Morell, and Lorri A. Lee joined Dr. Prielipp as panelists.

APSF-NYPGA Safety Panel

Robert K. Stoelting, MD, was joined by Drs. Jeffrey M. Feldman, Michael A. Olympio, and Lorri A. Lee for a panel entitled APSF Safety Initiatives:The Role of Educational Videos in Changing Clinical Practice on Monday, December 15, during the 2014 annual meeting of the NYPGA.

Prevention and Management of Operating Room Fires

Since its introduction in February 2010, more than 7,000 individual requests for a complimentary copy of the 18-minute educational DVD entitled
Prevention and Management of Operating Room Fires ( have been received. In an effort to increase awareness for the potential of surgical fires in at risk patients, APSF has created a Fire Prevention Algorithm Poster and an OR Fire Prevention Flyer that are available for download from the APSF website (

The goal of the APSF Fire Prevention Algorithm to increase awareness of the risk of operating room fires was endorsed by ASA, AAAA, AANA, ASATT, American College of Surgeons, ASPAN, Association of periOperative Registered Nurses, ECRI Institute, Food and Drug Administration Safe Use Initiative, National Patient Safety Foundation, and The Joint Commission.

Medication Safety in the Operating Room

To date nearly 3,000 individual requests for the complimentary copy of the 18-minute educational DVD entitled Medication Safety in the Operating Room: Time for a New Paradigm ( have been received.

Financial Support

Financial support to the APSF from individuals, specialty and components societies, and corporate partners in 2014 has been most gratifying. This sustained level of financial support makes possible the undertaking of new safety initiatives, the continuation of existing safety initiatives, and funding for anesthesia patient safety research. The level of research support is particularly dependent on the level of financial support received.

Online Donations

The link for on line donations to APSF is Contributions may also be mailed to the Anesthesia Patient Safety Foundation, 1061 American Lane, Schaumburg, IL 60173-4973.

Concluding Thoughts

APSF thanks retiring Board Directors Gerald Eichhorn, Walter Huehn, Kim Kraft, RN, and Michael O’Reilly, MD, and welcomes new directors, Lynn J. Reede, CRNA, Shane Angus, AA-C, Heidi Hughes, Susan Carter, RN, Ana P. McKee, MD, and Shane Varughese, MD.

As in the previous annual report, I wish to reiterate the desire of the APSF Executive Committee to provide a broad-based consensus on anesthesia patient safety issues. We welcome the comments and suggestions from all those who participate in the common goal of making anesthesia a safe experience. There remains much still to accomplish and everyone’s participation and contributions are important.

Best wishes for a prosperous and rewarding year 2015.

Robert K. Stoelting, MD President