Volume 3, No. 3, pp 17-28
September 1988
Table of Contents

New York State Regulations To Be Implemented
Safety To Be Featured at October ASA
Letters to the Editor
Simulators Endorsed As Anesthesia Training Tool
Current Questions in Patient Safety
From the Literature: Safety, Cost Strategies
From the Literature: Capnography
Patient Safety Key Theme of 9th World Congress
Anesthesia Safety Symposium Held 'Down Under'
Australians Start Own Safety Foundation
Anesthesia Assistants: A Timely Idea for Safety
ICPAMM Conference Reviews Safety Research
Letters to the Editor: Care Team Vs. Solo The Human Factor
NASA Safety Newsletter

New York State Regulations To Be Implemented

Work Hours, Resident Supervision, Anesthesia Monitors Mandated

by David E. Lees, M.D.

Work rules for the duration of call and supervision of house officers in New York, proposed last year, are about to become reality. Likewise, specific electronic monitoring during anesthesia will soon be required by state regulation.

The New York State Hospital Review and Planning Council endorsed new regulations for the revised Hospital Code on June 9. These now only await the approval of the Commissioner of the New York State Department of Health. The revised NYS Hospital Code states that as of July 1, 1989, resident hours other than in the emergency department will be limited to 24 continuous hours within the hospital. Nor can the weekly total exceed 80 hours per week when averaged over four weeks.

Clinical tours of duty must be separated by at least eight non-working hours. Also, senior attending physicians will be required to be on duty in the hospital 24-hours a day to provide contemporaneous and immediate on-site supervision of house staff.

Additionally, hospitals must review each resident's credentials and specify in detail his or her clinical privileges. The mechanism for review leads to assignment of residents to one of three categories regarding invasive procedures. Depending on the resident's knowledge and experience, he or she will be able to (1) perform a specific procedure alone, (2) under the general or indirect supervision of an attending physician or (3) only with immediate direct supervision and observation by the attending physician.

These elements in the new Hospital Code arose as a consequence of the "Libby Zion affair" in which the daughter of Sydney Zion, an influential lawyer and writer died in a New York City hospital after allegedly receiving improper care. An impaneled Grand jury in Manhattan investigating the death implicated unsupervised and fatigued residents as contributory in the death. In response to this, Dr. David Axelrod, Commissioner of Health appointed an Ad Hoc Advisory Committee on Emergency Services (the "Bell Committee") to make recommendations on the supervision and working hours of residents in teaching hospitals. It was these Bell Committee recommendations that became the substance of the new hospital code

At a recent meeting of the New York Society for Thoracic Surgery in February of this year, Dr. Axelrod discussed the Bell Committee report and answered questions from medical educators in the audience. Dr. Axelrod spoke of his "wider view of public health" and the need for equal distribution of preventable risk. He sees systemic problems in teaching institutions and, much like a modem day Flexner, he feels there is a need for immediate government intervention. He points to a failure of the voluntary sector to adjust to the rapidly changing hospital environment which is ever-increasingly dominated by sicker patients. Coupled with this, he sees an, inordinate faculty emphasis on practice income which has eroded teaching and supervision.

Poor Outcome From Inadequate Supervision

Dr. Alfred Gellhorn, co-chairman of the Advisory Committee on Physician Recredentialing, and the NYS Department of Health's Director of Medical Affairs also spoke at this meeting. Dr. Gellhorn is well known to medical educators throughout the State for his efforts as the chairman of the Council on Graduate Medical Education which seeks to reduce and reallocate the number and type of residency training positions in New York. Dr. Gellhorn stated that as a result of the Malpractice Act of 1985 which set up an adverse incident monitoring system, the New York State Department of Health had determined that poor patient outcomes could be directly linked to inadequate resident supervision; thus, according to Dr. Gellhorn, an existing problem was only highlighted by the Libby Zion case. More incidents appear to occur on nights and weekends when there is less supervision. He also pointed out that the average intensity of each case is increasing and the decreased patient contact time due to DRG mandated short stays only aggravates the problem.

Formidable Cost

New York City's Health and Hospital Corporation (HHC), which is the largest provider of municipal health care in the country, estimates that for its hospitals alone, it will cost a minimum of $58 million more per year to both provide for the ancillary staff and attending physician staff necessary to comply with these new regulations. These municipal hospitals are likely to be the hardest hit as their budget are already strained with the ever-increasing cost of AIDS cam It is estimated that by 199 1, the cost of AIDS care in New York City will total more than one billion dollars. The Greater New York Hospital Association representing the private and voluntary hospitals placed the cost of replacing the lost resident hours at an additional $80 million annually. The cost for the whole state has been put at over $200 million by the Commissioner's office. It is still unclear where the funding will be found to implement these radical changes. The Department of Health proposes that hospitals receive more funding through increased reimbursements under DRGS. Whether it be from the public coffers or from third party payers, the public will ultimately assume the cost of the-se changes either through taxes or increased

costs. The Bell Committee, in its report of October 7, 1987, made 17 distinct recommendations; the last was that "AU the recommendations are based on the understanding that the Department of Health will make available to hospitals the necessary funds to implement the recommendations." Hospital administrators and medical educators remain skeptical that funds will be forthcoming.

Little Planning

Despite the seeming inevitability of these regulations during evolution of the proposal over the last I 8 months and the discussion and debate they have triggered, few hospitals have made definitive contingency plans to deal with the changes. To meet the expected shortfall, particularly in junior resident hours, some institutions are considering expanding senior resident hours or adding nurse practitioners, while others plan to add physician assistants or full-time house physicians

Various Responses

Traditional physicians and educators may see this as a major encroachment on graduate medical education and a compromise of patient cam Those with more moderate pedagogical views recognize the need for some reform but fear that by cutting daytime hours to allow continued night call, resident training experiences will be reduced; residents will attend fewer lectures and conferences and thereby have less interaction with senior staff. The more liberal educators and public health officials see this as a major advance that will soon spread throughout the country. They claim that it will both improve patient care and attract better residents to New York. Commissioner Axelrod sees this as a major advance in physician training and quality assurance. He anticipates that hospitals will relieve valuable house staff of the burden of scut work by hiring less skilled and cheaper ancillary personnel to perform these tasks.

The new Hospital Code also specifically addresses appropriate anesthesia monitoring. Section 405.13 on Anesthesia Services in its provisions states the following requirements:

"All anesthesia care shall be provided in accordance with accepted standards of practice and shall ensure the safety of the patient during the administration, conduct of and emergence from anesthesia. The following continuous monitoring is required during the administration of general and regional anesthetics... During the administration and conduct of all anesthesia on and after January 1, 1989 the patient's oxygenation shall be continuously monitored to ensure adequate oxygen concentration in the inspired gas and the blood through the use of a pulse oximeter or superior equipment. During every administration of general anesthesia using an anesthesia machine, the concentration of oxygen in the patients breathing system shall be monitored by an oxygen analyzer with a low oxygen concentration alarm... For every patient receiving general anesthesia with an endotracheal tube, the quantitative carbon dioxide content of expired gases shall be monitored through the use of end tidal carbon dioxide analysis or superior technology. In all cases where ventilation is controlled by a mechanical ventilator, there shall be in continuous use an alarm that is capable of detecting disconnection of any components of the breathing system."

It is axiomatic that the regulatory environment is event-driven. This is certainly true in aviation and increasingly so in medical care. These described changes to the Hospital Code in New York reflect a growing disenchantment by State public health officials with the traditional voluntary consensus organizations and professional guilds that have overseen medical education, clinical care and practice standards to date

Dr. Lees is Professor and Chairman of Anesthesiology at New York Medical College and a member of the Editorial Board of the APSF Newsletter.

Does the advent of strict governmental practice regulations portend a return to simpler times and techniques in anesthesia and surgery?

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Safety To Be Featured at October ASA

Patient safety in anesthesia will once again be a major component of the presentations at the American Society of Anesthesiologists' annual meeting in San Francisco, October 812. Various types of presentations will cover different aspects of the field.

Among the refresher course lectures on Sunday, October 9, will be a presentation "Anesthetic disasters: Causes, incidence and preventability" given by Dr. R.L. Keenan. Also in the morning, Dr. J.H. Eichhorn will discuss quality assurance in anesthesia. Later in the same day, Dir. J.A. Katz will present a refresher course on "management of intraoperative ventilatory emergencies:'

Among the workshops is one at 9 AM on Tuesday, October 11 on "needed research in patient safety." On the following day, there will be a workshop on "quality assurance' from 9 AM to 12 noon, and a workshop on "anesthesia machine obsolescence" from 2 to 4 PM.

Several of the formal presentations, both scientific paper and scientific poster, will deal with topics related to patient safety. In the sessions on patient safety and epidemiology will be presented a paper on the effect of obesity on the safe duration of apnea in patients, particularly during laryn8oscopy. ALSO, a paper generated from the ASA Closed claim Study concerning the impact of the severity of an injury on the way the mishap causing the injury is reviewed by various anesthesiologists will be presented. A discussion of the nasal insulation of oxygen as a way to prevent hypoxemia in apneic patients, such as during laryngoscopy, will be discussed. Findings regarding tracheal injury from the pressure of endotracheal tube cuffs and ways to prevent it will be presented. Finally, as an example of application of new research techniques, a paper will he given on "meta-analysis" as a new graphical and statistical technique to amalgamate the findings of many different research studies with the goal of attempting to help prevent adverse outcome from anesthesia.

Several papers in the sessions on monitoring relate to patient safety in anesthesia. There will be a paper on differentiating esophageal from tracheal capno8rams. Another paper will discuss the cascade of monitoring detection of anesthesia disaster. This work discusses accidents, such as circuit disconnects and failure of the oxygen supply, deliberately created in instrumented animals under general anesthesia. The sensitivity and specificity of various monitoring modalities was then studied over the course of evolution of events subsequent to these deliberate "accidents:'

Also, in the sessions on monitoring will be a paper on malignant hyperthermia and the clean anesthesia machine as well as a presentation on a simple pulse monitor for use during magnetic resonance imaging. Another paper will discuss an approach to "smart alarms" in anesthesia monitoring with the intention of suggesting that "rule-based" expert systems can potentially minimize unnecessary alarm events, consolidate alarm information, and suggest potential diagnoses in the course of adverse events. A different type of discussion will take place in a paper regarding the reproducibility of capnographic measurements in sedated patient receiving supplemental oxygen by nasal cannula while having exhaled carbon dioxide measured from the nose at the same time.

This list of presentations at the annual meeting is only a sampling of the multiple activities related to patient safety that will be available to anesthesiologists attending the annual meeting. Further details on these and other related presentations will be available in the meeting materials.

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Letters to the Editor

Leaving Regional Block Patients Alone, Nurses Extubating Seen Acceptable

To the Editor:

I find myself strongly disagreeing with the views expressed by Dr. Jene regarding leaving a patient in the operating room unattended, and the view of Mr. Clark Fenn regarding extubation of patients in the recovery room by the recovery nursing staff (APSF Newsletter, June 1988).

The issues involved in leaving a patient unattended in the operating room are those of safety and comfort for the patient. I will readily agree with Dr. Jene that patients having general anesthesia or central neuraxis blocks (spinals or epidurals) should not be left alone until they are safely back on the ward after recovery from the anesthetic.

Peripheral nerve blocks are another matter entirely. Many times, and in many institutions, such blocks are done by surgeons in clinical settings where monitoring is done by a nurse or aide or not at all while the procedure is done. Then the patient is sent home or to a ward bed to complete the recovery from his block. I see no difference between this and doing a peripheral nerve block in the operating room and leaving the patient after the adequacy of the block is demonstrated.

Certainly safeguards are appropriate to ensure safety. These must include observation for at least a half hour after the injection of the block to ensure that there is no evidence of a toxic reaction to the local anesthetic used. There must also be at least a half hour of observation after any sedation. In no circumstances should a patient be left alone if he is so sedate that he is essentially asleep. But the patient who is awake, comfortable, who speaks when spoken to, and whose vital signs are stable within acceptable limits may be safely left without an anesthesiologist in personal attendance. Our experience confirms the safety of this practice

The issue of having nurses extubate patients in the recovery room is reminiscent of the arguments about nurses giving hypodermic injections or starting intravenous lines. These arguments over the legally defined scope of practice beg the issue of whether the patient is being cared for properly, and revolve around "turf protection".

In our facility we have a protocol established for nurses to use in deciding to extubate and in carrying it out. It is set up to guide their judgment to ensure that the patient after extubation will continue to maintain an adequate airway and breathe effectively. In the use of this protocol over the past four years we have had no serious problems. In fact, we have not had to reintubate any patients because a nurse following this protocol has made an inappropriate decision.

Kenneth R. Noel, M.D. Anesthesia Department Naval Hospital San Diego, CA

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Simulators Endorsed As Anesthesia Training Tool

To the Editor:

I write to express my enthusiasm for the idea of having anesthesia simulators. I read the article in the March APSF Newsletter. Simulators can do a lot for us in anesthesia. They will allow the anesthesiologist to be periodically (once a year?, twice a year?) exposed to a variety of situations that otherwise he/she would see only very rarely, if ever. Through this exposure, recognition as well as reaction time and institution of corrective measures will undoubtedly improve.

With today's computer technology (hardware/ software), one simulator could be accessible to many anesthesiologists. There could also be different levels of operation and sophistication.

The cost of such a simulator, s 10,000,000, is a great deal of money but it is the amount often paid in a single settlement of a malpractice suit originating in events that this simulator will help prevent. A few simulators could be strategically placed throughout the country making access possible for all practicing anesthesiologists. The expenses of building such simulators could be paid by recruiting a coalition of malpractice insurance companies, health insurance companies, health care providers and others. Operation and maintenance could be sold through a matching program including users fees.

If users would be rewarded with substantial premium discounts from their malpractice insurance companies, I believe most anesthesiologists would be willing to participate.

Work on automated record keeping will play a definite roll in the acquisition of data to build such a simulator.

Anesthesiologists need simulators. The simulator's automated anesthesia record keeping and monitoring will bring our specialty genuinely to the computer age.

0. Mario Carlomagno, M.D. Knoxville, TN

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Current Questions in Patient Safety

Response to Anesthesiologist Absent from OR

Question: "We have a staff person who insists on leaving a patient alone on a ventilator in an OR while he takes breaks. He has been counseled by the department chairman and hospital administrator, but still persists in this action. What should be the next step in dealing with this problem?"

Answer: Dealing with the problem of an anesthesiologist leaving a patient unattended is very straightforward if the Anesthesiology Department/Section has the appropriate Guidelines/Rules/Policies written to cover such action, i.e., adoption of ASA Standards for Basic Intra-operative Monitoring. Ignoring departmental policies or rules should be grounds for disciplinary action within the department or the hospital medical staff. The by-laws of the medical staff should cover disciplinary action at the department level first, and possibly higher level action, such as loss of privileges at the hospital medical staff level.

The first ASA standard requiring the anesthesiologist's presence in the OR should be a "given" in any department. AD of the above, plus the comments of Drs. Zauder and Jene in the APSF Newsletter of June, 1988 are the ideal situations. There are anesthesiologists practicing in this country who do not fit the idea, i.e., there is no one to relieve the practitioner for even short periods during the day or night. In most practice situations, it is unthinkable that a patient should be left during a case under general anesthesia. However, we must realize that all do not practice in Utopia, and having one anesthesiologist for a small community hospital is better than none.

In conducting a consultation through the ASA On-Site Program, it is evident that situations exist that are not ideal, i.e.-, small, isolated hospitals with one anesthesiologist, or a 200-bed acute care hospital in which four anesthesiologists are "stretched" to cover the OR, OB and emergency schedule. There may be extenuating circumstances, defensible cases in which an anesthesiologist leaves the OR for very short periods and designates a temporary substitute after evaluating the potential risks and benefits.

Through the On-Site Program, it is hoped that ASA may be of assistance to the-se hospitals that are seeking a solution to understaffing.

Answer by Betty P. Stephenson, M.D., Houston, TX who is a member of the ASA Peer Review Committee.

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From the Literature: Safety, Cost Strategies

Editor's note: In each APSF Newsletter, a pertinent publication from the anesthesia patient safety literature will be summarized. Suggestions for future issues are welcome.

Gravenstein JS, Holzer JF: Safety and Cost Containment in Anesthesia Butterworths, Stoneham, MA, 1988.

Safety and Cost Containment in Anesthesia edited by an anesthesiologist, I.S. Gravenstein, M.D. and a risk manager who is an attorney, I.F. Holzer, provides a basic overview of the increasingly complex relationships of anesthesia patient safety, risk management, and cost-containment. The book is essentially the proceedings of a 1987 symposium at the University of Florida sponsored by the APSF and Ohmeda. It presents the viewpoints of some of the leading experts in national anesthesia risk management and includes perspectives from experts in the field of law, medicine, insurance, hospital administration, and manufacturing.

Part I of the book examines the potential risks and causes of adverse anesthesia-related incidents and injuries, a subject most anesthesiologists are aware of but unfamiliar with. Part 11 of the book expands on this theme by providing an excellent review of how anesthesia-related mishaps financially impact not only the physician, but also the manufacturer, the insurer, and the legal profession. Parts III (Improving anesthesia safety today and in the future) and IV (financial decision making with respect to anesthesia safety) of the book examine what steps need to be taken by the physician and hospital administrator to reduce anesthesia risk and optimize patient safety in an environment of increasing cost containment. Part V (Current issues) considers the pro and con side of standards in anesthesia and of automated records. Also covered is the use of simulators in training and the question of re-certification for anesthetists. The authors of the various sections review the current standards of anesthesia monitoring and provide concrete suggestions as to how anesthesiologists can eliminate risk factors that may lead to adverse events.

Safety and Cost Containment in Anesthesia provides an excellent and timely overview of a very complex subject. It is easy to re-ad, and its multidisciplinary approach to the subject is both refreshing and informative. The book is recommended to all anesthetists and administrators who are frustrated with the ever-growing complexities in the anesthesia and health care industries and want a guide to help them through the maze. In the final analysis, everyone connected with anesthesia benefits from this type of publication, especially the patient.

Abstracted by Robert H. Bode, Jr., M.D., Harvard Medical School and New England Deaconess Hospital

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From the Literature: Capnography

Editor's note: In each APSF Newsletter, a pertinent publication from the anesthesia patient safety literature will be summarized. Suggestions for future issues are welcome.

Gravenstein J.S., Paulus D.A., Hayes T.J.: Capnography in Clinical Practice Butterworths, Stoneham, MA, 1988.

The recognition Of C02 as a significant monitoring parameter and the availability of simplified advanced technology made C02 measurement (inspired and expired) both clinically desirable and feasible. Professional organizations associated with design and implementation of patient safety standards, after demonstrating convincingly the major benefits Of C02 monitoring, became strong advocates for such measurements. This is the beginning of capnography, capnometry, or capnoscopy, as it is called by some. The bioelectronic industry, capitalizing on the opportunity, made available in a relatively short time devices to be used for this purpose in the everyday clinical practice. Unfortunately, such technological proliferation left the ordinary dini6an somewhat uninformed on this issue.

This monograph on capnography, the only current text on the subject, is a timely presentation that not only will alleviate confusion but will help the anesthesiologist better understand and utilize capnography. Capnography and capnometry, in addition to providing information concerning production and elimination Of C02, are important safety tools which, if properly used, will decrease catastrophic anesthesia accidents associated with technical misadventures with endotracheal tubes and ventilation.

The monograph addresses the issue in a rather broad spectrum. Presentation of capnography in three sections gives the reader the opportunity to direct his attention to the section pertinent to daily practice, yet allows him to refer to the physiology and technologic perspectives of capno8raphy at his leisure. The last section gives the reader a chance to formulate opinions about the performance and limitations of the functional characteristics of the devices available today. The pictures, diagrams and illustrations are clear and the references appropriate. In general, this is a very well thought out and well written monograph which undoubtedly will be a significant plus in any library associated with clinical anesthesia practice. Particularly, it will be a help for the practitioner, resident, or student seeking insight into this timely topic.

Abstracted by Israti A. Kupeli, M.D., Harvard Medical School and New England Deaconess Hospital.

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Patient Safety Key Theme of 9th World Congress

by John H. Eichhorn, M.D.

"Vigilance' was the theme of the 9th World Congress of Anesthesiologist's nx2fing, May 22-28 in Washington, IDC. Accordingly, anesthesia patient safety was one of the many topics featured throughout the presentations of the Congress.

Thirty-one papers on patient safety and risk management were presented in two sessions during the week. Subjects ranged from the flammability of tracheal tubes exposed to laser to a discussion of whether or not dantrolene prophylaxis in malignant hyperthermia patients is really necessary. One paper suggested that small amounts of water taken orally, even in the immediate preoperative period, had no effect on the risk of acid aspiration.

A comprehensive report of an occurrence screening program in a major anesthesia training center was presented. Nearly 7,000 cases were screened with a comprehensive check-6t tool. The incidence of cardiac arrest during anesthesia was 0.07% and the incidence of intraoperative death was 0.04% while perioperative deaths accounted for 0. 16% of the cases. The check-list tool was felt to be very sensitive and specific for picking up both these major and a long list of relatively minor anesthesia complications.

Other papers discussed the use of an outcome index to measure the quality of care in anesthesia. There were studies of the incidence of cardiac arrest associated with spinal anesthesia and associated with death on the operating table over the last 25 years, both these studies coming from Japan. There was a discussion of the prevention of major intraoperative anesthesia accidents through minimal safety monitoring. Discussion was presented regarding the hazards of injections into intravenous tubing and a paper regarding protocols to help minimize drug administration errors was also very well received.

Panel Discussions

Two panel discussions on anesthesia patient safety were presented combining to create an all day session. Dr. I.B. Cooper reviewed studies on anesthesia mishaps, noting that there are a wide variety of mortality and morbidity statistics from different studies over different time periods and using different techniques. He suggested that human error accounted for an avoidable cause of anesthesia mishap in at least half the reported cases. He detailed the "mishap process" which involves human error associated with other factors, such

10 as a decrease in vigilance and a deficiency in human factors, such as equipment design, all combined as a coincidence in time to yield an anesthesia accident.

Dr. I.B. Forrest presented a discussion of the relative risks of anesthesia from his studies in Canada. Dr. D.M. Gaba presented a discussion of human error. He stressed the role of anesthetist bias in the development of problems during anesthesia, in the sense that there is a tendency to assume that things are air tight until it is patently obvious that they are not. He stressed that it is important to recognize that problems will occur during anesthesia and that there needs to be improved "rule-based" responses. He suggested that there should be a redundancy in monitors and alarms and more training in how to deal with emergencies. This will result from an improved knowledge base coming from increased education and possibly the assistance of artificial intelligence in the future.

Fatigue Data Shown

An extremely interesting discussion of fatigue and vigilance was presented based on experience in the American military. While overall performance on motor tasks can remain relatively near baseline for up to 18 hours, it was noted that there can be a decrement in vigilance (decreased efficiency, more incorrect responses, and slower responses when correct) starting as soon as 30 minutes into a task with a marked decrease at two hours of a continuous task. It was noted that this was why there are four-hour shifts in the extremely high vigilance tasks in the military. It was suggested that all these factors are intensified following a period of sleep deprivation. Discussion of the concept of sleep debt and the need for relatively long unbroken periods of sleep to recover from this debt illustrated why broken sleep or intermittent naps are insufficient to restore performance after sleep deprivation. Potential applications to the current concerns about the length of working hours for anesthetists were discussed.

What Makes a 'Good' Anesthetist?

The selection and training of anesthesiologists was discussed at length and an analogy was made to the same processes for commercial pilots. Extensive discussion took place regarding potential predictors of success as an anesthetist and the final conclusion was that it is extremely difficult if not impossible to accurately gauge who will make a good anesthetist. Aspects of training of anesthetists to maximize safety in practice were discussed.

Several presenters from around the world discussed features, such as the quality of care in the United Kingdom, standards of practice in the Netherlands, monitoring of a healthy patient in Switzerland, the role of the anesthesia machine in the Federal Republic of Germany, and also problems in funding of anesthesia safety programs.

The panel sessions were wrapped up with a session by Dr. E.C. Pierce, Jr., President of the APSF, on the prevention of anesthesia mishaps.

Throughout the World Congress, there was a patient safety booth operated among the exhibits at which information about the APSF and its safety efforts and programs was available to all Congress attendees.

Dr. Eichhorn is Editor of the APSF Newsletter.

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Anesthesia Safety Symposium Held 'Down Under'

by Dr. GM Purcell

Over 300 Australian anesthetists met in Sydney on June 18, 1988 to consider the present status of the "Patient safety" issue, to gain insight into changes in American standards of practice as presented by Dr. E.C. Pierce, Jr., and to discuss the "Monitoring During Anesthesia" document endorsed by the Board of the Faculty of Anesthetists, Royal Australian College of Surgeons, in early June 1988.

Continuing review by Professor Ross Holland of the deaths reported to the New South Wales Anesthetic Mortality Committee, reinforced that the majority (over 90%) of deaths attributable to anesthesia were avoidable and that the utilization of monitoring apparatus, and in particular oximetry, could have influenced and possibly reduced such mortality by 40%.

Professor Holland observed that the majority of deaths however remained due to human error in the form of inappropriate assessment, techniques, and management, and that a large proportion of the problems arose in the recovery unit. He encouraged the continuation of monitoring modalities well into the recovery phase. He confirmed that of the monitoring modalities available, oximetry more than all other forms, may have prevented mortality in the post-operative period.

Dr. Richards Morris reviewed the impact of oximetry on clinical practice and untoward events, observing that oximeters remain vastly better than the "clinical signs" involved in detecting hypoxia and that they are generally accurate and reliable. However, their performance may be diminished by movement, poor perfusion, and the presence of confounding factors e.g. methylene blue and carbon monoxide. He noted that clinical practice has improved with the presence of oximeters, if practice is quantified by the number of "de-saturation" events occurring intra and post-operatively. Oximeters can be readily demonstrated to be cost effective especially when recorded to diminish the incidence of "high payout" catastrophic events.

Professor Bill Runciman, Adelaide, presented the Faculty's recommendations, which primarily state that the basis of patient care is by clinical monitoring by a vigilant, appropriately trained and constantly present medical practitioner.

The patient must have the following monitored: Circulation by detection of a pulse and measurement of arterial pressure, Respiration by continuous observation of rate and depth, and adequacy of Oxygenation by appropriate frequent observation.

Such clinical monitoring should be supplemented by:

1) An automatically activated oxygen supply failure alarm must be fitted.

2) An inline inspired oxygen analyzer should be in continuous use.

3) A pulse oximeter must be exclusively available for every anaesthetized patient.

4) Electrocardioscopy and a temperature monitor should be available for every anaesthetized patient.

5) A carbon dioxide monitor and a neuromuscular function monitor should be available for those patients where it is indicated.

An overall program was regarded as necessary within each department for professional and insurance carrier satisfaction. This included: (i) a mechanism to review and diminish "risk factors" associated with anesthetic delivery; and (ii) establishment of a functional quality assurance committee within a department, which developed specific anesthetic quality indicators and actively detected, evaluated, and reported on morbidity and modes of practice.

Dr. Purcell is Chairman, N.S.W. Anesthetic Continuing Education Committee.

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Australians Start Own Safety Foundation

by Dr. WB. Runciman

At the conclusion of the Meeting in Adelaide in May, 1987, it was agreed that a body called the 'Australian Patient W Foundation; be established as a non-profit organization with the aim of promoting, organizing, funding, conducting research into, and establishing mechanisms for advancing patient safety in anesthesia care.

This organization has now been formed, and the central office has been located within the new academic Department of Anesthesia and Intensive Care at the Royal Adelaide Hospital. Strong links have been established with the Therapeutic Devices Evaluation Committee of the Australian Commonwealth Department of Community Services and Health, with the Emergency Care Research Institute in the United States, and with the National Safety Council of Australia, Victorian Division. Four persons have been employed. These comprise an experienced anesthetist with an interest and expertise in computing, two biomedical engineers and an office manager.

The organization will have a number of specific immediate aims: (1) To conduct equipment evaluation studies. (2) To organize and conduct 'workshops' and 'think tanks'. (3) To organize and conduct educational activities and courses. (4) To provide handbooks and manuals for procedures and equipment. (5) To promote, organize and coordinate incident reporting and critical incident reporting studies. (6) To promote, conduct workshops and carry out medical decision analyses. (7) To promote, advise and coordinate the setting up of computer orientated anesthetic records and records of procedures. (8) To offer services related to patient safety. (9) To act as a clearing house for information. (10) To be self funded.

The interface between biotechnology and man is evolving very rapidly. Many groups are expending much effort in pursuing their legitimate interests in this area. These activities are not always necessarily consistent with the pursuit of patient saw. The APSF (Australia) was formed in recognition of the growing need for an independent body to promote the exchange of information from the perspective of those on the receiving end the patients. It is hoped that it will constitute a vigorous body which will provide infrastructure and funding for research and projects in as many anesthetic departments and practices as possible.

Dr. Runciman is Professor of Anaesthetics, Royal Adelaide Hospital.

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The Faculty of Anesthetists, R.A.C.S. recommends the monitoring of certain fundamental physiological variables during anesthesia. Clinical judgment will determine how long monitoring should be continued following completion of anesthesia.

Some or all of these basic recommendations will need to be exceeded routinely depending on the physical status of the patient, the type and complexity of the surgery to be performed, and the requirements of anesthesia. Occasionally some of the recommended methods of monitoring may be impractical or inappropriate. Departments of Anesthesia should establish policies to deal with such circumstances.

The following recommendations refer to patients undergoing general anesthesia or major regional anesthesia for diagnostic or therapeutic procedures and should be interpreted in conjunction with other policy documents published by the Faculty of Anesthetists. AU policy documents are revised from time to time as required by changing clinical practice and developments in technology.

The Health Care Facility in which the procedure is being performed is responsible for provision of equipment for anesthesia and monitoring on the advice of one or more designated specialist anesthetists, and for effective maintenance of this equipment.


Clinical monitoring by a vigilant anesthetist is the basis of patient care during anesthesia. This should be supplemented by appropriate devices to assist the anesthetist.

A medical practitioner whose sole responsibility is the provision of anesthetic care for that patient must be constantly present from induction of anesthesia until safe transfer to Recovery Room staff or Intensive Care Unit has been accomplished. Such medical practitioner must be appropriately trained in Anesthesia, or be a Trainee Anesthetist supervised in accordance with the Faculty Guidelines for Supervision of Trainees. (Faculty Policy Document E3 (1986))

It is recognized that brief absences of the person primarily responsible for the anesthetic may be unavoidable. In such instances that person shall delegate, temporarily, observation of the patient to a medically qualified person who is judged to be competent for the task.

The individual anesthetist is responsible for monitoring the patient and should ensure that appropriate monitoring equipment is available. Where there is an environmental risk to staff, e.g. radiation, adequate facilities must exist to enable remote patient monitoring.


2.1 Circulation

The circulation must be monitored at frequent and clinically appropriate intervals by deW6on of the arterial pulse and measurement of the arterial blood pressure.

2.2 Respiration

Respiration must be monitored continuously by observation of rate and depth.

2.3 Oxygenation

The patient must be observed at frequent intervals for evidence of central cyanosis. If an oximeter is in use its displayed values should he assessed by frequent observation of the patient.


The following recommendations for equipment should be implemented as soon as possible, and in any case no later than 1st January, 1990:

3.1 Oxygen Supply Failure Alarm

An automatically activated device to monitor oxygen supply

pressure and to warn of low pressure must be fitted to the anesthetic machine.

3.2 Oxygen Analyze

A device incorporating an audible signal to warn of low oxygen

concentrations, correctly fitted in the breathing system, should be in continuous operation for every patient when an anesthetic machine is in use.

3.3 Pulse Oximeter

Pulse oximetry provides evidence of saturation of the hemoglobin of arterial blood and identifies arterial pulsation at the site of application. A pulse oximeter must be exclusively available for every anaesthetized patient.

3.4 Alarms for Breathing System Disconnection or Ventilator Failure

When an automatic ventilator is in use, a device capable of warning promptly of a breathing system disconnection or ventilator failure must be in continuous operation. It is desirable that this device be automatically activated.

3.5 Electrocardiograph Equipment

To monitor and continually display the electrocardiograph should be available for every anaesthetized patient.

3.6 Temperature Monitor

Equipment to monitor temperature should be available for every anaesthetized patient.

3.7 Carbon Dioxide Monitor

Monitoring of tidal carbon dioxide should be available for those patients where it is clinically indicated.

3.8 Neuromuscular Function Monitor

Monitoring of neuromuscular function should be available for those patients where it is clinically indicated.

3.9 Other Equipment

When clinically indicated, equipment to monitor other physiological variables should be available.

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Anesthesia Assistants: A Timely Idea for Safety

Anesthetists in Other Countries Routinely Have Help During Cases

In the U.K.:

In the U.K., anesthetists can receive assistance during the administration of anesthesia under either of two systems.

The first system is based on "Anesthetic Nurses". However, these are not nurse anesthetists such as you have in the U.S.A. Our Anesthetic nurses are firstly SRNs (State Registered Nurses) who join a hospital offering the joint Board of Clinical Nursing Studies Course No. 182 in Anesthetic Nursing which is approved by the English National Board. At the end of the period of study the nurse has an examination conducted locally by the hospital department concerned and, if successful, is given a certificate, again by the local hospital.

The best known center which operates this system of Nurse Anesthetists is the Nuffield Department of Anesthetics in Oxford. Apart from here, with only three exceptions, all other hospitals in the U.K. work under the second (ODA) system described below. Anesthetic nurses in the U.K. are not responsible for administering anesthetics: they assist in the preparation and setting-up of equipment and act as a skilled and dedicated assistant to the Anesthetist (help with the puncture, application of cricoid pressure, etc.).

The alternative to the above is a system which uses ODAs (Operating Department Assistants). These are men and women who serve much the same function as the nurses in the first system. However, they are also trained as surgical assistants (they may "scrub up") as well as being responsible for surgical equipment. Trainee ODAs are recruited from Operating Department Orderlies (whose duties are mainly pottering) and school leavers. The minimum educational requirements are very variable but it is not unknown for some of them to possess a University degree!

ODAs undergo two years of training (which includes a minimum of 290 hours theoretical study plus a minimum of 35 weeks practical experience in each of anesthetics and surgery) in certain hospitals which have a designated training school. At the end of this time the candidates are examined by an Institute called the "City and Guilds" (C&G).

The C&G negotiates courses of education and training with the various hospitals to provide an integrated system of syllabuses, examinations and certification. The course number is C&G 752, and is run in association with the National Health Service (NHS).

The examination (MCQ) system for ODAs comprises a two-hour paper in each of Anesthetics and Related Subjects, and in Surgery and Related Subjects. The course work is also taken into consideration before which satisfactory completion of a record book of practical instruction and experience is required. Finally, practical assessments of the candidate are conducted in anesthetics and in surgery; safety measures form part of these assessments.

It is a matter of concern which extends over very many years that the pay of an ODA is abysmal. A trainee starts at $6,550, rising to $8,270 on qualification with $1 1,800 for a Senior ODA on the maximum point of the scale. These dedicated men and women are thus financially grossly abused and can only make ends meet by overtime working and agency locums.

The Association of Anesthetists of Great Britain and Ireland has made a special study of the subject of "Assistance for the Anesthetist".

Professor A. P. Adams

Department of Anaesthefics

Guy's and St. Thomas' Hospitals London.

In Australia:

Anesthetic assistance is a variable entity in Australian practice. The principle persists that assistance is essential for safe and efficient conduct of anesthesia.

In up to 40% of cases, an assistant designated exclusively to assist the Anesthetist/s at all times is available. Such a person's qualifications vary; they may be an Anesthetic assistant (usually an enrolled nurses aide), an Anesthetic Sister (a State registered nurse) or an Anesthetic technician (usually with a Technical Diploma). An Anesthetic and Operating Room Technician's Diploma course is available in Sydney, conducted through the Royal Prince Alfred Hospital and affiliated with an Institute of Technology.

The skills and training of all the above "assistants" are variable, however, any in-house training and support provided by anesthetists is usually reciprocated.

Otherwise, for the majority of cases, an O.R. Sister is designated to provide anesthetic assistance at the induction and conclusion of anesthesia. She may very well be the "scout nurse" for the operative period.

Anesthetists generally concur with the Faculty of Anesthetist's guidelines espoused in the Faculty's Policy Statement "Minimum Assistance Required for the Safe Conduct of Anesthesia".

However, they do not aggressively involve themselves in training programs for such assistants and are wary that an inadequately trained assistant, perhaps without commitment and an insight into what is happening, may be more of a liability than of value

Dr. GM Purcell, Chairman, N.S.W. Regional Committee, Faculty of Anesthetists,

Royal Australian College of Surgeons.

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Minimum Assistance Required for the Safe Conduct of Anesthesia


1. I Assistance for the anesthetist is essential for the safe and efficient conduct of anesthesia.

1.2 This assistance requires:

1.2.1 The presence of an assistant during preparation for and induction of anesthesia, until the anesthetist indicates that the assistant is no longer required.

1.2.2 The availability of an assistant if required during the maintenance of anesthesia.

1.2.3 The presence of an assistant at the conclusion of anesthesia.

1.3 These principles apply wherever the anesthetic is given.

1.4 Institutions in which anesthetics are given must provide a service which ensures the availability and maintenance in good order of equipment in accordance with Faculty documents on recommended minimum facilities for safe anesthetic practice.

1.5 Staff employed for all of the above purposes must be adequately trained for their role.


2.1 The deployment of assistants in accordance with 1.2 above, should be specified by management protocols.

2.2 The nature and workload of the Anesthetic Service will determine the number and status of persons acting as assistants.

2.3 The duties of an assistant should be specified by a job description.

2.4 Whilst assisting the anesthetist, the assistant is wholly and exclusively responsible to that anesthetist.

2.5 The assistant is an essential member of the staff establishment for each area in which anesthetics are given.

2.6 Rosters and establishment for areas in which anesthetics are given must allow for the availability of adequately trained assistants at all hours.

2.7 For administrative and educational reasons, where a number of assistants are employed, one of their number who is appropriately trained should be designated in charge

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ICPAMM Conference Reviews Safety Research

by Jeffrey B. Cooper, Ph.D.

A meeting of the International Committee for Prevention of Anesthesia Mortality and Morbidity was held on May 22 in Washington, D.C., just prior to the World Congress. There were 61 invited participants, representing 19 countries. ICPAMM is an informal communication network among individuals involved in studying anesthesia mortality and morbidity and related issues or who are involved in creating or implementing policies aimed at anesthesia patient safety.

The primary objective of this meeting was to review recent studies with emphasis on experimental methods. In particular, presenters were asked to share experiences about the relatively successful and not so successful aspects of their investigations.

Six studies we-re described during the morning session: Confidential Inquiry on Perioperative Deaths (United Kingdom) (1), Randomized Trial of Four Anesthetic Regimens (U.S./Canada), Analysis of Malpractice Closed Claims (U.S.)(2), Prospective Critical Incident Survey (Australia), Manitoba Study (Canada)(3) and Recovery-Room-Impact Events Study (U.S.)(4). It became clear in the course of discussions that the study of anesthetic outcomes has become of intense interest in the anesthesia communities of many countries. Further, patient safety is similarly high on the agenda of research and clinical interests.

Morbidity, Mortality

The presentations of M&M investigations illustrated the spectrum of anesthesia outcomes and the ways that they can be studied. Dr. John Lunn described how the CEPOD reviewed reports of deaths within 30 days of a half million operations in three regions of the U.K. Reviewers analyzed these and attributed cause to surgical disease, intercurrent disease, surgery or anesthesia, or a combination of those. The study of malpractice closed claims, reported by Dr. Fredrick Cheney, examined records of 17 insurance companies. Here, only anesthesia-related claims were reviewed and the reviewers assessed appropriateness of care, involvement of error, and preventability. Because there is no denominator of the total number of operations represented, no incidence can be computed. The outcomes include not only death but other injuries (excluding dental).

Dr. Forrest described how the randomized trial among ten hospitals recorded outcomes in 17,201 patients who were randomized across four anesthetic drugs (halothane, enflurane, isoflurane and balanced). Nearly 86% of patients had some form of "outcome" as defined by this study. The vast majority of these, of course, resulted in no untoward longterm sequalae. The study represents the kind of methodology that is required to test hypotheses, in this case, "Do differences exist among the different anesthetic drugs?"

Large Studies

Dr. Marsha Cohen described the Manitoba Study in which adverse outcomes were documented for approximately 1 12,000 patients in one large teaching hospital. Here, all patients were carefully screened by a smaller group of anesthetists, assuring better validity of the outcome data. The overall rate of outcomes was substantially different than that in the randomized trial, owing to the differences in definitions of "outcomes:' This demonstrates how careful one must be in interpreting and comparing studies.

The study on "recovery-room-impact-events," described by Dr. Jeffrey Cooper, illustrates yet another outcome measure, similar to that defined in the Manitoba Study. Potentially harmful, anesthesia related events, requiring intervention and continuing care in the recovery room were documented. The overall rate of the-se was not too dissimilar from that in the Manitoba Study. This study illustrated how such outcome measures can be used to test the effects of clinical interventions. But, as Dr. Cohen described in her presentation, none is as powerful or elegant as the randomized trial technique.

Each presentation offered insight into the realities of anesthetic risk, interpretation of research or news about new activities. CEPOD demonstrated that cooperation between anesthesiologists and surgeons in outcome studies is possible. The study provides some comfort in revealing that very few people die solely as a result of causes attributable to anesthesia (11185,000). But concern still exists over the 14% of patients to whose deaths anesthesia at least partly contributed. A positive effect of the study was that surgeons and anesthetists are now meeting to jointly discuss their practices and that ongoing reporting of deaths has now been established. The identification of inadequate supervision of junior anesthetists as a frequent mortality related finding is prompting closer examination of this issue. Dr. Lunn explained that the anonymity and confidentiality and legal protection provided were at least partially responsible for the success of CEPOD. He also noted that intense personal contact with participants and their hospitals is required to obtain meaningful cooperation.

Dr. Forrest indicated how difficult it is to organize a massive randomized trial. A particular problem is obtaining consensus among a large pool of investigators (22 in this case). Intense attention to detail is required to assure that the participants and their institutions understand the study and adhere to the protocol. Verification of data similarly requires a tremendous commitment of resources. In summarizing the study, Dr. Forrest reported his assessment that, while some differences among the four anesthetic regimens were identified, these were relatively minor and probably don't contribute in a major way to anesthetic risk. He believes that the condition of the patient and the person administering the anesthetic are probably more important than which anesthetic drugs are used.

Dr. Robert Webb described the foundation of a new Australian Anesthesia Patient Safety Foundation. It is non-profit and is privately financed. An anesthesia incident monitoring study has also been established in Australia and is planned to include 50 hospitals and 500 anesthesiologists. Its purpose is to collect critical incidents and analyze that information and share it among the Australian anesthesia community. A vital fink in the study will be the person-on-the-spot (POS) located in each participating institution and responsible for motivating cooperation and ensuring credibility of data.

ASA Closed Claim Study

In describing the closed-claims study, Dr. Cheney reported that analysis of inter-rater reliability is an important new component of their work. Such assessments are vital in the design of outcome investigations where reviewers are used. It was comforting to find that among 42 raters of 48 case summaries there was a high degree of agreement on the appropriateness of care and on the involvement of human error. Agreement on assessing prevention by better monitoring was somewhat less but still quite reasonable(Specific data will be reported in a manuscript in preparation.) The value of the closed-claims review methodology is demonstrated in the way that it identified an interesting subset of deaths and injuries following sudden cardiac arrest from spinal anesthesia and in providing information to assess the potential of monitoring technologies to prevent untoward outcomes(5).

The Manitoba Study offers many lessons. Again, careful study design and attention to detail are required for credibility. All of the centers involved must use similar instruments. Code books must be prepared to define all data items; all participants and data coders must be trained and indoctrinated into the objectives of the study. An appropriately designed anesthesia record can be an instrument for collecting outcome data. But, the design of that re-cord must recognize potential discomfort of documenting complications. Combining the same document for anesthesia billing with collection of outcome data is a good vehicle for improving compliance. The importance of a dedicated, well trained program coordinator, with appropriate clinical background and the respect of other clinicians is vital to the success of such efforts.

In describing the study of RRIES, Dr. Cooper noted how carefully planned experimental designs can be altered by uncontrollable events. To test for the effects of feedback of information to participants, a six month control period and a six month experimental period were planned. This was based on estimates of the required sample size for sufficient statistical power to test the hypothesis. Plans to introduce pulse oximetry sooner than had otherwise been anticipated forced a change in the sampling periods. The smaller sample size impeded testing of the hypothesis although reasonable statistical power was still obtained. Still, this illustrates the extreme difficulty in controlling all of the potentially confounding variables in longitudinal clinical experiments.

During discussions at the ICPAMM Meeting, other participants briefly mentioned ongoing studies in Norway (Dr. Gisvold), in South Africa (Dr. Gaisford Harrison) and in Denmark (Drs. Pederson and Trier Moeller). Dr. Arman Bunatien briefly reported on data collected recently in Moscow. Dr. Harrison summarized results of studies that reflect the decreasing rate of deaths attributable to anesthesia over the past several decades (0.41 1 000 to 0.0711000).

Dr. J.S. Gravenstein described the APSF sponsored survey of fatigue among anesthesiologists. (By this time, analysis of the survey should be underway). His report prompted interest from two other countries in which it is hoped that the same survey will be distributed. The discussion following his presentation indicates that fatigue and work hours are of interest in other countries. In Brazil, the maximum number of working hours for house staff is limited to 60 hours by law. Dr. John Zelcer reported on a study that is underway in Australia to assess the effects of fatigue on performance. And, it is noted that regulations limiting length of continuous work hours also exist in various states of Australia and Canada.

Dr. Helmut Schwilden presented results of a survey recently conducted in several European countries with the objective of assessing what anesthetists monitor during anesthesia. His presentation documented that there are indeed wide variations in anesthesia practices among European states. A large majority of respondents said that they had experienced a situation where a monitoring device detected a life-threatening complication before they would have themselves based on clinical signs alone. There is apparently a need for education among anesthesiologists about the function of various forms of monitoring. Since the majority of the sampled anesthesiologists were residents, the implication is for intensified educational efforts in training programs.

Trainee Selection

Dr. Davies reviewed the literature on the personality of anesthetists and the question of whether personality was related to accidents and could be used in the process of selecting trainees. Although studies have evaluated anesthetists' personalities, it is not clear if the subspecialty constitutes a distinct "species." And, no profile of which anesthetist might be prone to accidents is known. A four-year, prospective study of anesthetic residents in Canada, Southern Ireland, and France is planned to better establish the personality characteristics and attitudes of anesthesia practitioners.

Dr. Zairo Viero spoke about patient safety in Latin America, where facilities for anesthesia are very different than the industrialized countries. Electronic monitoring equipment is rare and even where it exists, its useful fife is short due to the unavailability of spare parts. Human resources must be the basis for improving safety. More training programs are generally needed. These must recruit anesthesiologists of the target country. Foreign training often results merely in the loss of talent.

The ICPAMM discussions prompted many useful connections for future studies. The next meeting is scheduled for Warsaw in 1990.


1. Buck, N., Devlin, H.&, Lunn, J.N.: The Report of a Confidential Enquiry into PERIOPERATIVE Deaths. The nUFFIELD Provincial Hospitals Trust, 3 Prince Albert Road, London, 1987.

2. Cheney FW: Anesthesia: Potential risks and causes of incidents in Safety and Cost Containment in Anesthesia. Gravenstein IS and Holzer IF, eds. Butterworths, 1988.

3. Cohen, M.M., Duncan, P.G., Pope, W.D. and Wolkenstein, C.: A Survey of II 2,000 Anesthetics at One Teaching Hospital (1975-83). Can Anaesth Soc

33:22-31, 1986.

4. Cooper, I.&, Cullen, D.J., Nemeskal, R., Hoaglin, D.C., Gevirtz, C.C., Csete, M., Venable, C.: Effects of information feedback and pulse oximetry on the incidence of anesthesia complications, Anesthesiology 67:686-694, 1987.

5. Caplan RA, Ward RJ, Posner K and Cheney FW: Unexpected cardiac arrest during spinal anesthesia: A closed claims analysis of predisposing factors. Anesthesiology 68:5-11, 1988.

Dr. Cooper, Massachusetts General Hospital, is the organizer of ICPAMM and a member of the APSF Executive Committee.

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Letters to the Editor: Care Team Vs. Solo The Human Factor

To the Editor:

I have been so delighted to receive your publication and see the development of a scholarly approach to anesthesia patient safety. Each and every study of patient injury that I see elucidates the importance of the human factor in the prevention of anesthesia-related injuries.

I am increasingly concerned that there is developing view point which states that a sole anesthetic practitioner, usually a physician, is the best approach to anesthesia patient care The airlines clearly reject this view, and it is well known that two and sometimes more responsible professionals are in the cockpit of every commercial flight in this country and abroad.

Presently my practice involves the anesthesia team approach to anesthetic care involving an anesthesiologist and CRNA with our practice limited to usually supervising two operating rooms, but on occasion, a third operating room supervised by the same attending anesthesiologist. I have experienced in the last several years numerous occasions when the dictum "two heads were better than one" proved efficacious in patient care. Here were cases in which our nurses or our physicians in a joint effort were able to notice some factor of potential harm and corrected the problem prior to any injury. Our present clinical arrangement allows me to concentrate very carefully on medical work-up of patients, the medical aspect of their care, and without a question in my view, adds to the quality of our anesthetic care.

I would be most interested in your Foundation presenting relevant articles on the important issue of solo anesthesia practice as opposed to team anesthetic practice with a direct emphasis on solving the human factor of anesthetic-related injuries. Please seek responses from some of your knowledgeable colleagues. I hope to see an article or perhaps the results of a study specifically dealing with the human factor when compared between solo practitioners and team practitioners.

Donald Mundy, M.D.

Burlington, North Carolina

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NASA Safety Newsletter

The Ames Research Center of the National Aeronautics and Space Administration (NASA) publishes a monthly safety bulletin entitled Callback which comes from NASA's Aviation Safety Reporting System (ASRS). While this newsletter deals in large measure with human factors in aviation safety, it is often relevant to the practice of anesthesiology.

A recent issue, for example, dealt with the "standard dilemma of how much rope to allow a student before instructor intervention to alleviate the student's risk of hanging himself?" This is a perennial problem which any anesthesiologist or CRNA working in a teaching hospital has experienced. This bulletin as well as other ASRS in-depth studies of ergonomic consideration in safety are available free upon request from:

Office of the NASA Aviation Safety Reporting System

P.O. Box 189

Moffett Field, CA 94035

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The Anesthesia Patient Safety Foundation Newsletter is the official publication of the nonprofit Anesthesia Patient Safety Foundation and is published quarterly in March, June, September, and December at Overland Park, Kansas. Annual membership: Individual $25.00, Corporate $500.00. This and any additional contributions to the Foundation are tax deductible @Copyright, Anesthesia Patient Safety Foundation, 1988.

The opinions expressed in this newsletter are not necessarily those of the Anesthesia Patient Safety Foundation or its members or board of directors. Validity of opinions presented, drug dosages, accuracy and completeness of content are not guaranteed by the APSF.

APSF Executive Committee: Ellison C. Pierce, Jr., M.D., President; W Dekle Rountree, Jr., Vice-President; E.S. Siker, M.D., Secretary; Burton A. Dole, Jr., Treasurer; Jeffrey & Cooper, Ph.D.; Joachim S. Gavenstein, M.D.; James E Holzer, J.D.

Newsletter Editorial Board: John H. Eichhorn, M.D., Stanley 1. Aukburg, M.D., Jeffrey M. Beutler, C.R.N.A., M.S., Ralph A. Epstein, M.D., David E. Lees, M.D., Bernard V. Wetchler, M.D., Mr. Mark D. Wood

Address all general, membership, and subscription tion correspondence to:

Administrator Anesthesia Patient Safety Foundation

515 Busse Highway

Park Ridge, IL 60068

Address Newsletter editorial comments, questions, letters, and suggestions to:

John H. Eichhorn, M.D. Editor, APSF Newsletter; Dept. Anesthesia

Beth Israel Hospital, DA-717 Boston, MA 02215

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