Volume 1, No. 1 • Spring 1986

Safety Foundation Organized

Jeffrey B. Cooper, Ph.D.; Ellison C. Pierce, M.D.

Statement of Purpose

This is the first Newsletter of the Anesthesia Patient Safety Foundation, which was incorporated on September 30, 1985. The mission of the APSF is clear and simple-to encourage activities that will prevent patients from being harmed by the effects of anesthesia. Why such a foundation? What activities shall it promote to fulfill its mission? What resources will support those activities? What can you do to help?

It is generally agreed that anesthesia is safer than it has ever been, but that it still isn’t safe enough. In the United States, annually some several thousand patients die or are seriously injured at least in part by their anesthetic experience. Them is strong evidence that more than half of these adverse outcomes are preventable by applying known precepts of anesthesia management. Yet, the causes of preventable deaths and injuries are diverse and complicated. There is no one evil and no simple cure.

The first step toward improvement is creating awareness that a problem exists. Education, training, application of current and developing technologies and acquiring new knowledge about the causes and prevention of mishaps are components of a solution matrix.

Anesthesia mortality is everybody’s problem. Most people will be exposed to the risk several times in their life. When a bad outcome occurs, it affects not only the patient, but has a lasting impact on the family, the anesthetist, and the anesthetist’s colleagues as well. It is also a problem for many other constituencies-the manufacturer and designer of equipment that is involved or implicated in an accident and the hospital administrator in whose operating room an accident occurred. For the companies that provide liability insurance, there is the clear and present danger that the malpractice crisis, caused at least in part by preventable injuries, may severely damage or cripple the viability of their organizations. That this crisis puts the entire health care system in jeopardy makes this a problem for the federal government also.

Because there has been no place that these constituencies can join forces to promote change, the Anesthesia Patient Safety Foundation was formed. Its goals are:

*To foster investigations that will provide a better understanding of preventable anesthetic injuries;

*To encourage programs that will reduce the number of anesthetic injuries; and

*To promote national and international communication of information and ideas about the causes and prevention of anesthetic injuries.

During the first year, the Foundation’s aims are to start a communication vehicle (this newsletter) and to establish a research fund, awarding several grants. Committees have been created to implement these activities.

Who is the APSF? Its 30 -member Board of Directors includes representatives from anesthesiology, nurse anesthesia, device and pharmaceutical manufacturing, the insurance industry, hospitals, biomedical engineering, and the FDA (see page 5 of this newsletter for a complete list of the Board and committees). Membership in the APSF is open to any individual contributing at least $25 and any corporation contributing at least $500. Contributions will go toward funding the cost of producing and distributing this newsletter to the approximately 45,000 people who have a stake in preventing anesthesia injuries and toward the support of safety-related research activities.

You won’t have to be a member of the APSF to benefit from its efforts but, yes, you will receive a certificate of membership if you join. The real reason to contribute $25 or more is because you want to make anesthesia safer. Because it can be. Because it should be. We think that some improvements, through increasing awareness and through implementing some new technologies, can be had in the short term-a few years. But, the ultimate goal of near-absolutely injury-free anesthesia will take longer because the impact of training, of education, and of innovative ideas derived from research take time to percolate through a culture. But, it can be done. We need your help.

Jeffrey B. Cooper, Ph.D.

Ellison C. Pierce, M.D.

For the Executive Committee

THE APSF EXECUTIVE COMMMEE recently met in Atlanta, GA. Left to right: Dr. ).S. Gravenstein, Dr. I. B. Cooper, Dr. E.S. Siker (Secretary), Mr. I.E Holzer, Dr. E.C. Pierce (President), Mr. B.A. Dole (Treasurer), and Mr. W.D. Rountree (Vice President).