October 2016 APSF Newsletter, The Official Journal of the Anesthesia Patient Safety Foundation


National Partnership for Maternal Safety—Maternal Safety Bundles

Professional Certification in Patient Safety

Functional Check of the Breathing Circuit

The Effect of General Anesthesia on the Developing Brain

The Role of Capnography to Prevent Postoperative Respiratory Adverse Events

Implementation of Emergency Manuals in China


ASA/APSF Pierce Lecture:
Safety Beyond Our Borders: Different but the Same

Invitation to Submit
and Deadline for January 1, 2018,
APSF Grant


APSF Board of Directors Workshop: Conflicts in the Operating Room–Impact on Patient Safety

Letters to the Editor:

Clear Plastic Causes Obstruction of Breathing Circuit

The Future of Emergency Manuals and Cognitive Aids

Rupture of Obstructed Nasal Cannula

Fluid Management Redux


Archives of Past Issues
Sponsorship Opportunities
Corporate Donors
2016 Board and Committees
APSF Newsletter Guide for Authors

—Featured Article—

National Partnership for Maternal Safety—
Maternal Safety Bundles

The United States is one of only eight countries worldwide and the only developed nation where maternal mortality has increased since 1990.1 Parturients in this country are three times more likely to die from pregnancy-related complications than women in Britain, Germany, or Japan.1 These findings are shocking, especially considering that prior to 1982 maternal mortality in the United States had improved dramatically over the last century.2 Improvement in survival can be attributed to advances in medical care, more hospital deliveries by those trained in obstetrical care, and better aseptic technique.3... [more]

Professional Certification in Patient Safety:
An Opportunity for Expanding the Horizons
for Anesthesia Professionals


Anesthesia professionals are leaders in patient safety and have been since before the Institute of Medicine brought widespread attention to the issue of medical error through its report, To Err Is Human. A combination of technological advances, education, awareness, and adoption of practices from other high-risk industries has resulted in anesthesiology becoming far safer today than it was 30 years ago.1

Still, we have a long way to go; health care is not yet as safe as it could be.2 The National Patient Safety Foundation (NPSF), like the Anesthesia Patient Safety Foundation (APSF), has a broad agenda for working with multiple stakeholders to advance progress in patient safety. And, like APSF, NPSF is committed to encouraging, promoting, and supporting the professional development of patient safety leaders. The leadership of APSF sees development of a cadre of anesthesia patient safety leaders as one of its most important strategic goals. [more]



ASA/APSF Ellison C. Pierce Jr., MD Patient Safety Memorial Lecture

Safety Beyond Our Borders:
Different but the Same



Anesthesia Patient Safety Foundation


APSF-Sponsored Conference

Conflicts in the Operating Room–
Impact on Patient Safety




The Official Journal of the Anesthesia Patient Safety Foundation

The Anesthesia Patient Safety Foundation Newsletter is the official publication of the nonprofit Anesthesia Patient Safety Foundation and is published three times per year in Wilmington, Delaware. Individual subscription–$100, Corporate–$500. Contributions to the Foundation are tax deductible. ©Copyright, Anesthesia Patient Safety Foundation, 2016.

The opinions expressed in this Newsletter are not necessarily those of the Anesthesia Patient Safety Foundation. The APSF neither writes nor promulgates standards, and the opinions expressed herein should not be construed to constitute practice standards or practice parameters. 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; Jeffrey B. Cooper, PhD, Executive Vice President; George A. Schapiro, Executive Vice President; Robert J. White, Vice President; Matthew B. Weinger, MD, Secretary; Casey D. Blitt, MD, Treasurer; Robert A. Caplan, MD; David M. Gaba, MD; Steven K. Howard, MD; Lorri A. Lee, MD; Robert C. Morell, MD; A. William Paulsen, PhD; Richard C. Prielipp, MD; Steven R. Sanford, JD; Maria A. van Pelt, PhD, CRNA; Mark A. Warner, MD. Consultants to the Executive Committee: John H. Eichhorn, MD; Bruce P. Hallbert, PhD.

Newsletter Editorial Board:

Robert C. Morell, MD, Co-Editor; Lorri A. Lee, MD, Co-Editor; Steven B. Greenberg, MD, Assistant Editor; Sorin J. Brull, MD; Joan Christie, MD; Jan Ehrenwerth, MD; John H. Eichhorn, MD; Glenn S. Murphy, MD; Wilson Somerville, PhD; Jeffery Vender, MD.

Address all general, contributor, and subscription correspondence to:

Administrator, Deanna Walker
Anesthesia Patient Safety Foundation
Building One, Suite Two
8007 South Meridian Street
Indianapolis, IN 46217-2922
e-mail address: walker@apsf.org

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

Robert C. Morell, MD
Senior Co-Editor, APSF Newsletter

c/o Addie Larimore, Editorial Assistant
Department of Anesthesiology
Wake Forest University School of Medicine
9th Floor CSB
Medical Center Boulevard
Winston-Salem, NC 27157-1009
e-mail: apsfeditor@yahoo.com

Send contributions to:
Anesthesia Patient Safety Foundation
1061 American Lane
Schaumburg, IL 60167-4973
Or please donate online at www.apsf.org.