Circulation 122,210 • Volume 30, No. 3 • February 2016   Issue PDF

President’s Report Highlights Accomplishments of 2015

Robert K. Stoelting, MD

Robert K. Stoelting, MD, President, APSF

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.

Ellison C. Pierce, Jr., MD, Patient Safety Memorial Lecture

A highlight of the opening session of the annual meeting of the American Society of Anesthesiologists in San Diego, CA on October 24, 2015 was the ASA/APSF Ellison C. Pierce, Jr., MD, Patient Safety Memorial lecture delivered by Mark A. Warner, MD. Dr. Warner’s topic was Expanding Our Influence: How the Perioperative Surgical Home Will Improve Patient Safety.

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.

APSF Board of Directors Workshop

The APSF Board of Directors Workshop occurred on Saturday, October 24, 2015. The topic for this 2-hour workshop was
“From APSF Educational Videos to your practice: How to make it happen.” During this workshop, the APSF educational videos, Prevention and Management of Operating Room Fires, Perioperative Visual Loss (POVL), and Simulated Informed Consent Scenarios for Patients at Risk for Perioperative Visual Loss were presented followed by small breakout sessions during which attendees met with members of the APSF Executive Committee and shared their opinions regarding strategies and impediments for implementing the recommendations in the videos. Drs. Jeffrey M. Feldman and Lorri A. Lee represented the APSF Board of Directors as co-moderators for the workshop.

Implementing and Using Emergency Manuals and Checklists to Improve Patient Safety

APSF held a consensus conference on this topic on Wednesday, September 9, 2015 (Royal Palms Resort and Spa, Phoenix, AZ). APSF believes there is a need for anesthesia professionals and other members of the perioperative care team to move towards the acceptance of cognitive aids (emergency manuals, checklists) and away from the traditional reliance on memory and the cultural perception of individual perfection. Cognitive aids include a variety of physical and electronic representations of knowledge “in the world” designed to assist those responsible for perioperative care in executing complex decision making in dynamic settings. This expert’s conference concentrated on the practical aspects of systematically implementing Emergency Manuals/Cognitive Aids and Checklists in the perioperative setting.

Developing the Relationship Between APSF and Large Anesthesia/Practice Management Groups

Following the September 9, 2015 conference on cognitive aids, APSF sponsored a half-day meeting on Thursday, September 10 with members of large anesthesia groups and representatives from practice management groups. The goal was for these representatives to meet with members of the APSF Executive Committee to discuss mutually relevant opportunities to address anesthesia patient safety issues and to incorporate potential solutions into best practices.

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. Demonstrating competency to use medical devices is consistent with safe patient care.

The 2015 report from the Committee on Equipment and Facilities recognized the universal agreement that individuals need to be adequately trained in the complexities of advanced medical technology in order to provide optimum safe care for patients. The most practical way to disseminate this information and make it easily accessible is through an electronic format that can be accessed through the Internet. It is vital that the content for this educational program come from the manufacturer’s engineers and technical specialists that developed the product to ensure that information is accurate. In that regard, it is being proposed that a fully ACCME-compliant path be developed that can include manufacturers’ participation. The most cost- and time-effective approach to establishing training of the many advanced technological devices used in anesthetic practice is to partner with manufacturers, providing appropriate and careful oversight of educational objectives and content to satisfy ACCME guidelines. As an initial project, it is proposed that ASA partner with manufacturers of anesthesia workstations to develop the educational tool for “teaching advanced medical technology” similar to previous ACCME-approved ASA workshops on the anesthesia workstation.


The APSF Committee on Scientific Evaluation chaired by Steven K. Howard, MD, received 44 letters of intent and invited eight investigators to submit completed applications for studies beginning January 1, 2016. In October 2015, the committee recommended funding two research awards totaling $297,374 (see article).

In addition to the traditional research grant awards, APSF continues its support of the APSF Safety Scientist Career Development Award (SSCDA) ($150,000 over 2 years). The current recipient is Meghan D. Lane-Fall, MD, MSHP, Department of Anesthesia, Perelman School of Medicine, University of Pennsylvania.

In July 2015, APSF and the Anesthesia Quality Institute (AQI) co-sponsored the APSF/AQI Patient Safety Career Development and Research Award with APSF and AQI sharing the cost of the grant award of $120,000. The current recipient of this award is Joseph A. Hyder, MD, PhD, Department of Anesthesia, Mayo School of Medicine.

In April 2015, the APSF Committee on Education and Training chaired by Richard C. Prielipp, MD and with assistance of committee members, Brian J. Cammarata, MD, Sandeep Markan, MD, and Lianne Stephenson, MD, announced the
APSF Resident Quality Improvement (QI) Recognition Program. Program submissions will consist of a brief written narrative and video submission describing the resident’s QI project. The two winners were announced at the Annual Meeting of the APSF Board of Directors meeting in October 2015 during the annual ASA meeting in San Diego, CA. The first and second place winners received financial awards of $1,000 and $500, respectively and the winning entries will also be showcased on the APSF website.

APSF is the largest private funding source for anesthesia patient safety research in the world. Since the inception of the APSF grant program, 779 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 105 grants for a total of more than $9,744,227. 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, acting as co-editors. Steven B. Greenberg, MD, has recently been appointed as Assistant Editor.

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 122,210. In addition to the electronic version of the APSF Newsletter, a hardcopy is mailed to all members of the ASA, AANA, AAAA, ASPAN, and ASDA.

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. Online donations to APSF are possible via the website.

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. Dr. Brull will complete his tenure on January 1, 2016. APSF and the journal, Anesthesia and Analgesia thank Dr. Brull for his outstanding leadership as the “first anesthesia patient safety section editor” for our specialty.

APSF-IARS Safety Panel

APSF sponsored a panel entitled Three Myths of Anesthesia Patient Safety at the March 2015 annual congress of the International Anesthesia Research Society. The panel was moderated by Richard C. Prielipp, MD, Chair, APSF Committee on Education and Training.

APSF-NYPGA Safety Panel

Robert K. Stoelting, MD, moderated a panel entitled APSF Safety Initiative: Implementing and Using Cognitive Aids (Emergency Manuals and Checklists) to Improve Patient Safety on Sunday, December 13 during the 2015 annual meeting of the NYPGA.

APSF-AANA Annual Meeting

APSF sponsored a 1-hour session at the 2015 AANA annual meeting. The topic was fire safety with Charles Cowles, MD, and Maria van Pelt, PhD, CRNA, presenting.

Prevention and Management of Operating Room Fires

To date, more than 8,000 individual requests for a complimentary copy of the
Prevention and Management of Operating Room Fires DVD ( video.php) have been received. APSF has also created a Fire Prevention Algorithm Poster and an OR Fire Prevention Flyer that are available for download from the APSF website (

Medication Safety in the Operating Room

To date, more than 3000 individual requests for a 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 2015 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 online donations to APSF is Contributions may also be mailed to the Anesthesia Patient Safety Foundation, 1061 American Lane, Schaumburg, IL 60173-4973.

Seeking Candidates for the Next APSF President

I informed the 2015 Annual Meeting of the APSF Board of Directors (October 24, 2015) that I will not be a candidate for President in October 2016. A Search Committee chaired by Robert A. Caplan, MD, has been charged with identifying candidates for the next APSF President with a term to begin October 22, 2016. The search process and deadline to receive applications (January 8, 2016) have been widely announced including in the
APSF Newsletter and on the APSF website. On October 22, 2016, at the Annual Meeting of the APSF Board of Directors, the Search Committee will recommend a candidate for the position of APSF President.

Concluding Thoughts

APSF thanks retiring Board Directors Robert A. Virag and John M. O’Donnell, CRNA, DrPH, and welcomes new directors, Jenney E. Freeman, MD, and Wanda O. Wilson, PhD, CRNA.

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 2016.

Robert K. Stoelting, MD President