“What Then?” and “What Now?” 35th Anniversary Edition of the APSF Newsletter

John Eichhorn, MD; Robert Morell, MD; Steven Greenberg, MD
The APSF Editorial Board reviewed 35 years of APSF Newsletter articles, prior to the COVID- 19 pandemic, and voted to establish the “top 10” most impactful articles to be highlighted in this special issue with the overall theme of “What Then?” and “What Now?”

The 35th Anniversary Issue Editorials Are Based on These Original Ten Articles

#1 ASA Adopts Basic Monitoring Standards
John H. Eichhorn, MD. Spring 1987.

Editorial: ASA 1986 Monitoring Standards Launched New Era of Care, Improved Patient Safety
John H. Eichhorn, MD

#2 From the Literature: ECRI Review Explains, Warns of OR Fires
Chester H. Lake, Jr., MD. Winter 1991.

Editorial: Surgical Fire Prevention: A Review
Charles Cowles MD; Chester Lake MD; Jan Ehrenwerth, MD

#3 Induced Hypotension Tied to Possible Vision Impairments
Ann S. Lofsky, MD; Mark Gorney, MD. Summer 1998.

Editorial: Postoperative Visual Loss (POVL)
Lorri A. Lee, MD

#4 Special Issue: Production Pressure – Does the Pressure to Do More, Faster, with Less, Endanger Patients? Potential Risks to Patient Safety Examined by APSF Panel
Robert C. Morell, MD; Richard C. Prielipp, MD. Spring 2001.

Editorial: Production Pressure and Anesthesia Professionals
Richard C. Prielipp, MD, MBA, FCCM

#5 Beach Chair Position May Decrease Cerebral Perfusion
David J. Cullen, MD; Robert R. Kirby, MD. Summer 2007.

Editorial: Why Worry About Blood Pressure During Surgery in the Beach Chair Position?
David J. Cullen MD, MS

#6 Managing Cardiovascular Implantable Electronic Devices (CIEDs) During Perioperative Care
Jacques P. Neelankavil, MD; Annemarie Thompson, MD; Aman Mahajan, MD, PhD. Fall 2013.

Editorial: Change of Pace: An Update on the Perioperative Management of Cardiovascular Implantable Electronic Devices (CIEDs)
Jacques P Neelankavil, MD; Annemarie Thompson, MD; Aman Mahajan, MD, PhD, MBA

#7 Monitoring of Neuromuscular Blockade: What Would You Expect If You Were the Patient?
Robert K. Stoelting, MD. February 2016.

Editorial: Residual Neuromuscular Blockade: A Continuing Patient Safety Issue
Glenn Murphy, MD

#8 National Partnership for Maternal Safety – Maternal Safety Bundles
Jennifer M. Banayan, MD; Barbara M. Scavone, MD. October 2016.

Editorial: National Partnership for Maternal Safety— Maternal Safety Bundles
Jennifer M. Banayan, MD; Barbara M. Scavone, MD

#9 The Effect of General Anesthesia on the Developing Brain: Appreciating Parent Concerns While Allaying Their Fears
Luke S. Janik, MD. October 2016.

Editorial: The Effect of General Anesthesia on the Developing Brain: Is it Time to Temper the Concern?
Luke S. Janik, MD

#10 Perioperative Brain Health—It’s Not All Positive Attitude, Exercise, and Superfoods
Nirav Kamdar, MD, MPP; Lee A. Fleisher, MD; Daniel Cole, MD. February 2019.

Editorial: Brain Safety: The Next Frontier for Our Specialty?
Nirav Kamdar, MD, MPP, MBA; Phillip E. Vlisides, MD; Daniel J. Cole, MD

Ten years ago, the APSF Newsletter celebrated its 25th year “Silver” Anniversary (https://www.apsf.org/wp-content/uploads/newsletters/2010/summer/pdf/APSF201010.pdf). In that commemorative edition, John Eichhorn, MD recapped the creation of the APSF and discussed its innovative accomplishments in patient safety. That issue also focused on the challenges ahead and APSF’s commitment to creating and promoting safety initiatives for improving care, research, education, awareness, and national/international exchange of information.

1986 – Reviewing the first issue of the APSF Newsletter, L-R: Burton Dole, Treasurer; Jeffrey Cooper, PhD, Executive Committee (EC); John Eichhorn, MD, Editor; Jeep Pierce, MD President; J.S. Gravenstein, MD, EC; James Holzer, EC; Dekle Roundtree, Vice President.

1986 – Reviewing the first issue of the APSF Newsletter, L-R: Burton Dole, Treasurer; Jeffrey Cooper, PhD, Executive Committee (EC); John Eichhorn, MD, Editor; Jeep Pierce, MD President; J.S. Gravenstein, MD, EC; James Holzer, EC; Dekle Roundtree, Vice President.

Ten years later we are celebrating our 35th Anniversary with the “Jade Issue.” Jade is the modern symbol for a 35th anniversary and a stone that is prized throughout the world. This symbol also represents the APSF’s recent international expansion of the Newsletter and outreach, which will be highlighted.

We hope that this special issue will inform our rapidly growing national and international readership about the importance of perioperative patient safety and APSF’s role in continuing to improve it for our patients.

The APSF Editorial Board reviewed 35 years of APSF Newsletter articles, prior to the COVID-19 pandemic, and voted to establish the “top 10” most impactful articles to be highlighted in this special issue with the overall theme of “What Then and What Now?” To place these articles in proper context, past and current editors provide their perspectives on the significance and role of the APSF Newsletter during their tenures.

John H. Eichhorn, MD:
Founding Editor 1985–2001

Front page of the first issue of the APSF Newsletter, Vol. 1, No. 1, March 1986, with a photo of the first APSF Executive Committee members.

Front page of the first issue of the APSF Newsletter, Vol. 1, No. 1, March 1986, with a photo of the first APSF Executive Committee members.

When the APSF was created in late 1985, the vision was that “No patient shall be harmed by anesthesia.” Central to pursuing this vision at that time in history was the creation and dissemination of a journal-quality publication that would be the centerpiece of all APSF activities, the integrated “final common pathway” for communication and coordination of research, education, initiatives, and debate. With this goal in mind, the APSF Newsletter was born.

As difficult as it may be for many to imagine today, in 1985, there was no internet/world wide web, public email, smartphones, or Google search engine. Printed newspapers, magazines, and, particularly for health professionals, journals were the principle sources of information flow and, importantly, influence on behavior. Accordingly, the APSF Newsletter was established as a quarterly printed “mini-journal,” mailed to all anesthesia practitioners and related professionals in the U.S. and to selected leaders in other countries. It was printed in black and white with bright green accents that were symbolic as they matched the color of American medical oxygen tanks, with the hope of triggering an identifying familiarity in the anesthesia community.

Detailed in the 2010 25th Anniversary APSF Newsletter (cited on the cover page) is the remarkably serendipitous sequence of coincidences that resulted in the establishment of the APSF, especially the passion of Ellison C. (“Jeep”) Pierce, Jr., MD. He became the inaugural APSF president and then approached me and asked if I could apply my past journalism and newspaper editing experience to creating the APSF Newsletter.

Note that the APSF was specifically created as a uniquely multidisciplinary and all-inclusive organization. Its initial leadership included two CEOs of major anesthesia machine manufacturers. Launching the Newsletter was facilitated in large part by the inaugural APSF Treasurer, Mr. Burton S. Dole, then CEO of Puritan-Bennett Corp. In addition to 33% of the seed money to establish the APSF, he generously offered the services of his company’s in-house print shop to typeset, proof, and print the APSF Newsletter.

The first issue of the APSF Newsletter was mailed out on schedule in March, 1986, to 45,000 recipients (ASA, AANA, risk managers, and corporate and international supporters). Beyond the lead story about the creation of APSF, there was a discussion of what was required for “minimal intraoperative monitoring,” and a report on the initiation of the ASA Closed Claims Study. Other stories covered the expansion of the Confidential Enquiry into Perioperative Death in England, statistics on cardiac arrest due to anesthesia at one teaching hospital, and the relative dangers of hypoxemia and hypercarbia. The first Newsletter was very well received, and it set the tone for all subsequent issues. Later the first year, there were presentations of an ECRI report on “Deaths during General Anesthesia,” verification of correct endotracheal tube placement, analysis of anesthesia deaths in Australia, and a report of decreasing anesthesia claims at one major insurance company. There was also an announcement of the first FDA anesthesia machine check-out protocol and reprinting of Jeep Pierce’s important article, “Risk Modification in Anesthesiology.” Standards figured prominently in early issues as there was extensive discussion of the 1986 ASA adoption of standards for intraoperative monitoring (see article on cover page) and also a variety of evolving anesthesia machine device and performance standards (fresh gas ratio protection, vaporizer exclusion, etc.) intended to enhance safety. Strong support for the universal use of intraoperative pulse oximetry, and then capnography, was a major early APSF theme.

One additional beneficial effect of the publication of the Newsletter was its value in helping the foundation’s fundraising efforts. Copies were sent to corporate officers of as many companies as could possibly be identified that provided products used in anesthesia practice. Results of these efforts were positive by the end of the 1980s. One company really helped the Newsletter. Hewlett-Packard, Inc., donated what was then new advanced technology: a desktop personal computer, a laser printer with lots of font cartridges, a scanner, and, most importantly, what was then a state-of-the-art word processing program. By 2020 standards, all this “technology” is archaic. But then it was revolutionary. Even though for some time the submissions still arrived on paper and had to be typed in, editing was much more efficient. Eventually, technology spread, and submissions could arrive on floppy disks sent via U.S. Mail. Galley proofs at the time were printed out and cut up with scissors and arranged like a puzzle to compose the pages of each issue on a template. In the late 1990s, Puritan-Bennett was acquired (for the third time) and was no longer available to print the Newsletter. Fortunately, that responsibility was taken up by another generous APSF corporate supporter, Mr. Bob Black, president of AstraZeneca, PLC. Production of the Newsletter, which was then over 60,000 copies, was moved to Wilmington, DE, where the production contractors were supported as a donation to APSF for many years. Several of those skilled and dedicated professionals continue to produce the Newsletter to this day.

Key Themes

During my 16 years as editor, the quarterly APSF Newsletter chronicled the now widely known story of the dramatic improvement in anesthesia patient safety, along with an abundance of features, reports, opinion pieces, controversial issues, and breaking news.

Concerns about look-alike medication labels and medication errors first appeared in the Newsletter in 1987 and persist today. The ASA Closed Claims Project was covered episodically as new safety issues were identified. The FDA equipment checkout protocol and checklist were first introduced to the anesthesia community in the Newsletter. A multitude of safety-related presentations, exhibits, and technology displays that appeared at a wide variety of meetings all over the world were routinely featured. Debates on the safety implications of practitioner fatigue, work hours, aging, and impairment, as well as discussions of obsolete equipment and reuse of disposables, appeared periodically. Off-site and office-based anesthesia came into existence during this era, and the special patient safety consequences were presented and debated in detail.

Many fundamental concepts in anesthesia patient safety and their implications for clinical practice were introduced in the Newsletter, including human factors in anesthesia practice, smart alarms in anesthesia delivery and monitoring systems, production pressure in clinical practice (as early as 1992 and, of course, persisting today—as are virtually all the other topics), crisis management in the OR, patient postoperative cognitive dysfunction, the danger of obstructive sleep apnea, wrong-site surgery, opioid overdose from PCA pumps, and even the Y2K computer bug doomsday predictions.

There were many “breaking news” items credited to the Newsletter that alerted the anesthesia community to new dangers, e.g., carbon monoxide production by carbon dioxide absorbents in certain situations, risk of succinylcholine administration in children, cardiac arrest from sympathetic blockade during spinals, neurologic complications from intrathecal 5% lidocaine administration, lidocaine toxicity from tumescent liposuction, sulfites in generic propofol causing anaphylaxis, and bacterial contamination of open propofol glass ampules. Still more “hot topics” included a recall of sevoflurane due to contamination, post-anesthesia blindness from ischemic optic neuropathy, a wide variety of equipment/supply issues (such as gas pipeline errors causing OR deaths), and specific human factors discussions, such as reading in the OR (which is now distraction from cell phone and Internet use).

At the end of 2001, I was privileged to turn over the editor’s position to a most worthy successor. Robert Morell, MD, had spent many hours helping me on the Editorial Board and then with production, all while learning the craft. He carried on mightily, bringing energy and innovation that, over his tenure, made me very proud, both of him and the APSF Newsletter.

Robert C. Morell, MD:
Editor 2002–2009 (and Co-Editor with Lorri A. Lee, MD, 2009–2016)

During the 2001 ASA Annual Meeting, at the APSF booth, John Eichhorn, MD (left), founding Newsletter Editor, turns over the page proofs and all good wishes to his successor Editor Robert Morell, MD.

During the 2001 ASA Annual Meeting, at the APSF booth, John Eichhorn, MD (left), founding Newsletter Editor, turns over the page proofs and all good wishes to his successor Editor Robert Morell, MD.

I initially became involved with the APSF and the Newsletter in 1993 when Rick Siker, MD, put me in touch with John Eichhorn, MD, who then encouraged me to attend and report on an FDA/Anesthetic and Life Support Advisory Committee meeting pertaining to safety regarding the use of succinylcholine in children and adolescents. John Eichhorn served as a mentor to me for that first safety reporting assignment, which resulted in a pro/con column published in the APSF Newsletter (https://www.apsf.org/article/in-my-opinion-a-debate-is-succinylcholine-safe-for-children/). He continued to be my mentor for many years as he encouraged my involvement with the Newsletter and appointed me to the Editorial Board. Eventually I became the associate editor and then succeeded John Eichhorn as editor-in-chief in 2001.

At that time the circulation of the APSF Newsletter was 36,825 and printed in black, white, and green. When I stepped down as editor in 2016, the circulation had grown to over 122,000, and it was printed in full color, with excerpts that were translated into Chinese due to the inspiration and efforts of Nikolaus Gravenstein, MD, and his Chinese colleagues.

As I reflect on the changes, progress, and impact of the Newsletter over those 15 years, it is strikingly evident that these successes were due to the incredible efforts of a number of wonderful and talented individuals. Michael Olympio, MD, was co-founder of the Dear SIRS (Safety Information Response System, now-known as Rapid Response) column (see page 99 for further information). He was a powerhouse leader of the APSF Committee on Technology (COT), contributing many important articles ranging from safety ramifications of anesthesia machine technology to a comprehensive review of the types of carbon dioxide absorbers and the safety ramifications of each.

Memorable Newsletter issues for me include a special issue on nuclear, biological, and chemical terrorism as well as the (now once again timely and important) issue on Severe Acute Respiratory Syndrome (SARS), which addressed both patient and clinician safety. Key contributions to patient safety have included extensive discussions of postoperative visual loss and ischemic optic neuropathy as well as the risks of cerebral hypoperfusion related to surgery in the sitting or beach chair position. The educational value of articles and reports and the APSF video related to intraoperative fire safety were important and extremely popular with the readership.

The Newsletter would not have succeeded were it not for the contributions of John Eichhorn, MD, and Editorial Board members such as Jeffery Vender, MD, Glenn Murphy, MD, Jan Ehrenwerth, MD, Joan Christie, MD, and Wilson Somerville, PhD. Also, Sorin Brull, MD, diligently read every word of every prepublication draft in addition to providing frequent and important content pertaining to issues of monitoring neuromuscular blockade along with annual comprehensive reports of all grant recipients. Richard Prielipp, MD, former chair of the APSF Education Committee has always been a role model and was the inspiration and facilitator for the initial and ongoing relationship between the APSF Newsletter and the journal, Anesthesia and Analgesia (A&A). A long-ago meeting in Chicago between Richard, myself, and then A&A Editor Steve Shafer, MD forged that incredibly important collaboration between the APSF and A&A, ably cultivated for many years by Sorin Brull and now Richard Prielipp.

Lorri Lee, MD, a world-renowned expert in neuroanesthesia and postoperative visual loss rose from Editorial Board member to associate editor and soon became co-editor. Lorri Lee, along with Bob Caplan, MD, and Karen Posner, MD, also provided ongoing guidance and content gleaned from their expertise in the ASA Closed Claims Database.

Steven Greenberg, MD, with tremendous expertise in critical care, cardiac anesthesia and neuromuscular blockade, contributed many important articles and provided amazing academic credibility and inspiration. Steve started as an Editorial Board member and soon rose to assistant and then to associate editor and finally became editor-in-chief upon my retirement. He has recently made the Newsletter even more influential as well as a truly international publication.

Over the 23 years of my involvement with the APSF, I was fortunate to participate in many important initiatives that have greatly improved patient safety. The Newsletter has always been, and continues to be, the face of the APSF, the means of communicating important and often critical information, and now, under the leadership of Steven Greenberg, serves as an international education tool. The Newsletter enjoys the largest circulation of any anesthesia publication in the world. None of this would have been possible without the support and guidance of former President Bob Stoelting MD, the Executive Committee, the Board of Directors, and most importantly, the Editorial Board. In memoriam, Rick Siker, MD, Jeep Pierce, MD, and J.S. Gravenstein, MD, were giants in patient safety and I was truly blessed to have known them and been inspired by them. I will always be grateful to all who have dedicated their selfless efforts and expertise and for the opportunity to have contributed to the APSF Newsletter and patient safety.

Steven B. Greenberg, MD: (Co-Editor with Lorri A. Lee, MD, 2017)
Editor-in-Chief 2018–Present

Mentorship is a relationship where a more experienced or knowledgeable person helps to guide a less experienced or knowledgeable person in a particular field or effort. It is the quintessential component to initiate and perpetuate successful patient safety endeavors. I have been fortunate enough to follow in the footsteps of “greatness.” From the moment one of my mentors, Jeffery Vender, MD, brought me to my first APSF Editorial Board meeting in 2007, I could see that room was filled with giants in the field of anesthesia patient safety. In particular, my predecessors, John Eichhorn, Robert Morell, and Lorri Lee clearly “walked the walk” when the time came to move the needle forward for safe perioperative patient care.

The APSF Newsletter though the years, starting with the original design under John Eichhorn; changes to the logo and format under Bob Morell; and our latest edition with the new branding under Steven Greenberg.

The APSF Newsletter though the years, starting with the original design under John Eichhorn; changes to the logo and format under Bob Morell; and our latest edition with the new branding under Steven Greenberg.

Patient Safety Initiatives Abound in the APSF Newsletter

The mentorship of John Eichhorn, Robert Morell, and Lorri Lee guided my efforts to build on the already successful enterprise of the APSF Newsletter. With their tutelage and my desire to continue the great traditions of the educational aspect of the Newsletter, we have strengthened our educational endeavors to address the 12 APSF patient safety initiatives that were voted on by our multidisciplinary, multiprofessional APSF Board of Directors. These are: 1) Preventing, detecting, and mitigating clinical deterioration in the perioperative period; 2) Safety in non-operating room locations; 3) Culture of safety; 4) Medication safety, 5) Perioperative delirium, cognitive dysfunction, and brain health; 6) Hospital-acquired infections and environmental microbial contamination and transmission; 7) Patient-related communication issues, handoffs, and transitions of care; 8) Airway management difficulties, skills, and equipment; 9) Cost-effective protocols and monitoring that have a positive impact on safety; 10) Integration of safety into process implementation and continuous improvement; 11) Burnout; and 12) Distractions in procedural areas. In addition, we have highlighted other important topics such as safe management of COVID-19 patients, local anesthetic systemic toxicity, alarm fatigue, and opioid-induced ventilatory impairment.

Diverse Editorial Expansion

The APSF has added to the Newsletter several excellent, talented editors, including Edward Bittner, MD, PhD, from Massachusetts General Hospital, Jennifer Banayan MD, from Northwestern Memorial Hospital, and Meghan Lane-Fall, MD, from the Perelman School of Medicine, University of Pennsylvania. These editors bring a vast amount of knowledge and expertise that continue to allow the APSF Newsletter to educate our readership on a broad scope of perioperative safety issues. In addition, our Editorial Board has also expanded to include every specialty within anesthesia and a multiprofessional presence. Finally, the APSF Newsletter in its current updated form, wouldn’t be what it is today without the incredible creativity and continued devotion of Bonnie Burkert and Jay Mahanna from MEBU Design & Marketing and the continued work of Celeste Pates, our project manager.

Communications Greatly Expand Scope

With our investment in communications, the APSF has hired Mike Edens and Katie Megan from EdensWorks, Inc., who have done an extraordinary job with helping the website grow and expand our global reach. The leadership and tireless work of both Arney Abcejo, MD, APSF website director, and Marjorie Stiegler, MD, APSF social media director have allowed the APSF Newsletter to occupy many different spaces in the complex digital world we know today. Edensworks, Inc. has provided the APSF Newsletter with data analytics on unique visitors to each article that we publish both nationally and internationally. With this analytic information, we are now able to select topics which best target our constituency with especially relevant patient safety information.

APSF Newsletter: An International Safety Educational Tool

In its original 1985 mission, one of the three axioms that the APSF wanted to promote was “national and international exchange of information and ideas (APSF Newsletter. 2010;25:21). Safe anesthesia care has no boundaries and, therefore, we have worked to establish an international translation program for the Newsletter. An article regarding the culture of Japanese anesthesia in 2016 by Katsuyuki Miyasaka, MD, sparked the creation of relationships with Hiroki Iida, MD, PhD, Tomohiro Sawa, MD, PhD, and many others to form the first-ever translated APSF Newsletter version in Japanese in 2017. This landmark issue provided a foundation for the development of countless other relationships with international safety professionals to develop and translate the APSF Newsletter to Chinese, Spanish, French, and Portuguese. Our international family of reviewers have provided insightful feedback on their relationship with the APSF (please see page 77). With continued engagement from our international reviewers, our editor group has developed an international editorial board which has over 10 active members and continues to grow.

The addition of our international program has increased our overall presence and allowed further expansion of safety knowledge for anesthesia professionals worldwide. Since its inception in 2017, the number of online unique visitors to the international newsletter has grown 3000% to approximately 370,000. In addition, with our efforts during the COVID-19 pandemic to inform our readership of the most up-to-date practices, the number of Newsletter unique visitors has grown 120% to 676,402. We plan on translation of the Newsletter into additional languages, and we will continue to strive towards disseminating current safety knowledge and practices to anesthesia professionals throughout the world to help keep all our patients safe.

The future is bright for patient safety in anesthesia care. We hope to combine education, research, initiatives, and outreach to further promote our vision that “No patient shall be harmed by anesthesia care,” and to continue to strengthen APSF’s reputation as an international hub for anesthesia patient safety information.


John Eichhorn, MD, was the founding editor and publisher of the APSF Newsletter. Living in San Jose, CA, as a retired professor of Anesthesiology, he continues to serve on the APSF Editorial Board.

Robert Morell, MD, was past editor-in-chief of the APSF Newsletter. He is a private practice anesthesiologist in Niceville, FL.

Steven Greenberg, MD, is current editor-in-chief of the APSF Newsletter. He is vice chairperson, Education, in the Department of Anesthesiology, Critical Care and Pain Medicine at NorthShore University HealthSystem and clinical professor in the Department of Anesthesia and Critical Care at the University of Chicago.

The authors have no conflicts of interest.