Anesthesia Patient Safety Foundation


Volume 18, No. 1, 1-16 Circulation 36,825

Spring 2003

Table of Contents

Special Issue: Safety First: Ensuring Quality Care in the Intensely Productive Environment—The HRO Model

Building a new safety culture must begin from the top down. M&M conferences, root cause analyses, failure mode and effects analyses, policies and procedures, and protocols are all important tools. This issue highlights the application of high reliability organizational (HRO) concepts to health care in general and the operating room in particular.

The flight deck of an aircraft carrier is a classic high reliability (HRO) model.
The operating room shares many characteristics and goals with other HROs such as aviation.

An HRO is an organization that repeatedly accomplishes its mission while consistently avoiding catastroptic consequences, despite high hazards, dynamic tasks, time constraints, and complex technology.

The APSF recognizes the dedication and sacrifice made by members of the military and their families.

The APSF continues to accept and appreciate contributions for the E.C. Pierce, Jr., MD, Research Award.

Please make checks payable to the APSF and mail donations to:

c/o Ellison C. Pierce, Jr., MD,
Research Award
4246 Colonial Park Drive
Pittsburgh, PA 15227-2621

The APSF wishes to thank
AstraZeneca Pharmaceuticals LP
for their continued support
of this newsletter.

Newsletter Named Official Journal of the APSF

The APSF Newsletter, which began in 1986 under the leadership of Dr. John Eichhorn, now reaches a new milestone by being named the "Official Journal of the Anesthesia Patient Safety Foundation." The Executive Committee of the APSF, in making this designation, recognizes the continuing contributions of the Newsletter to academic as well as clinical anesthesia, along with its primary function of disseminating safety-related news and information. While content submitted to the journal is not subject to a traditional peer review process, current topics are frequently presented in thoroughly referenced articles, by individuals with significant expertise and academic credibility. Examples have included discussions of perioperative beta-blockade, diagnosis and treatment of nuclear, chemical, and biological weapon exposure, Q-T prolongation with droperidol, ischemic optic neuropathy, obstructive sleep apnea, and ultrasound guided central venous cannulation. The current editor, Dr. Robert Morell, and the APSF Editorial Board will make every effort to present both articles and news items that will contribute to the APSF’s mission, which is to ensure that no patient is harmed by anesthesia.

Weapons of Mass Destruction Educational Task Force Now Available for Speaking Engagements

The APSF has sponsored the development of a task force on Biological, Chemical, and Nuclear Terrorism. Members of this task force include Drs. Douglas Coursin, Paul Morgan, Michael Murray, Richard Prielipp, and Mike Wall. Speaking engagements can be scheduled by calling Robin Williams at 904-296-5688 or email:

Virtual Anesthesia Machine Website Now Includes Chapter One of the APSF Anesthesia Machine Workbook

The Virtual Anesthesia Machine (VAM) program and APSF workbook were developed by Sem Lampotang, PhD and can be found on the web at: A link in the bottom center of the VAM home page allows one to view and/or print the workbook. All materials on the VAM website, including the animation and the APSF workbook, may be accessed free of charge. International users should note that the animation features the choice of Chinese, Dutch, French, German, Italian, Russian, Spanish, or English legends. Both the Virtual Anesthesia Machine and the workbook were prominently displayed at the APSF Booth at the recent ASA Convention in Orlando, Florida.

The Anesthesia Patient Safety Foundation Newsletter is the official publication of the nonprofit Anesthesia Patient Safety Foundation and is published quarterly at Wilmington, Delaware. Annual membership: Individual - $25.00, Corporate - $500.00. This and any additional contributions to the Foundation are tax deductible. ©Copyright, Anesthesia Patient Safety Foundation, 2003.

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:
Robert K. Stoelting, MD, President; Lori Cross, Vice-President; David M. Gaba, MD, Secretary; Casey D. Blitt, MD, Treasurer; Ellison C. Pierce, Jr., MD, Executive Director; Robert A. Caplan, MD; Nassib G. Chamoun, Jeffrey B. Cooper, PhD; John H. Eichhorn, MD; George A. Schapiro.

Newsletter Editorial Board:
Robert C. Morell, MD, Editor; Sorin Brull, MD; Joan Christie, MD; Jan Ehrenwerth, MD; John H. Eichhorn, MD; Regina King; Denise O’Brien, BSN, RN; Karen Posner, PhD; Keith Ruskin, MD; Wilson Somerville, PhD; Jeffery Vender, MD.

Addie Larimore, Editorial Assistant.

Address all general, membership, and subscription correspondence to:

Anesthesia Patient Safety Foundation
4246 Colonial Park Dr.
Pittsburgh, PA 15227-2621
e-mail address:

Address Newsletter editorial comments, questions, letters, and suggestions to:
Robert C. Morell, MD
Editor, APSF Newsletter
Department of Anesthesiology
Wake Forest University School of Medicine
9th Floor CSB
Medical Center Boulevard
Winston-Salem, NC 27157-1009