Perioperative Patient Safety Priorities

APSF’s Perioperative Patient Safety Priorities and Ongoing Activities

The following list contains our top 10 priorities and notes the activities for each that we have done in the past 5 years. The summary of activities is not exhaustive. Thank you to all of the APSF family who served with a Patient Safety Priorities Advisory Group (PSPAG) from 2021-2022. The 2023-2026 PSPAG information will be updated when they have begun their work.

APSF Activities:

Culture of Safety

Teamwork

Clinician Safety

  • Clinician safety (including burnout) will be will be the topic of the 2021 APSF Stoelting Conference
  • Five articles on this issue has been published in the APSF Newsletter
  • APSF has supported one research grant on this issue since 2016

Advisory Group:

Chair(s): Jonathan Cohen, MD; Toni Zito, MSN, RN, CPAN, FASPAN
Members: Elizabeth Malinzak, MD; Michael A.E. Ramsay, MD, FRCA; John Allyn, MD; Marilyn Archambeault, CAA; Amy Vinson, MD; May Pian-Smith, MD; Aalok Agarwala, MD; Amanda Lorinc, MD; Aubrey Samost-Williams, MD; Philip Greilich, MD; Shane Angus, CAA; Abigail Melnick, MD; Britany Thomas, CAA; Brad Taicher, DO, MBA; Sara Patel, CAA; Barbara Orlando, MD; Julia Feczko, CRNA; Karolina Brook, MD, CPPS; Jen Sanders; Teo Dagi, MD; Ryan Vincenzo, CRNA, MSN, EdD; Michael Noble; Junior Senat, CRNA; Barbara Burian, PhD; Ruth Fanning, MD; Patricia McGaffigan, RN, MS, CPPS; Daniel Pistone, CAA; Allison Doney, MHA; Michelle Beam, DO, MBA, FASA; Chase Sims, MD; Faiza Khan, MD; Brandi Bottiger, MD; Archit Sharma, MD, MBA; Ankeet Udani, MD; Sarah Whitfield, CAA; Jay York, MD; Meagan Devish, CAA; Amanda Stone, PhD; Jina Sinskey, MD; Bridget Pulos, MD; Chris Roussin, PhD; Leo Tabayoyong, PharmD; Patty Reilly, CRNA; Erica Brown, CRNA; Paul Czerwonka, CRNA

  1. Early warning systems in all perioperative patients
  2. Monitoring for patient deterioration
    1. Postoperative continuous monitoring on the hospital floor
    2. Opioid-induced ventilatory impairment and monitoring
    3. Early sepsis
  3. Early recognition and response to decompensating patient

APSF Activities:

  • The 2019 APSF Stoelting Conference was dedicated to this topic
  • This topic has been highlighted in 2020 APSF Newsletter issues and APSF-sponsored panels and presentations
  • APSF is collaborating with American Society of Anesthesiologists (ASA) and other subspecialty organizations to address specific issues related to this topic
  • APSF will support prototype development for several models that may reduce failure-to-rescue
  • APSF has supported 2 research grants on this issue in the past 5 years

Advisory Group:

Chair(s): Michael Scott, MB, ChB, FRCP, FRCA, FFICM; Jonathan Tan, MD
Members: John (JW) Beard; Tina Abdelnour, MS, BSN; Elise Hyman, VP, Marketing; Amir Ghaferi, MD; Michael DeVita, MD; Bryan Rondeau, MD; George Blike, MD; Carrie Menser, MD; J. Ross Renew, MD; Vikram Kumar, MD; Jack Neil, MD; Andrea Regan, MSc, MSA, CAA; Shermeen Vakharia, MD; Susan Hall; Christina Canfield, MSN, APRN, ACNS-BC, CCRN; Michael Noble; Alan Hendon, CRNA; Sheri Jones Oguh, MD

APSF Activities:

  • The APSF supports this ASA-American Association of Retired Persons initiative
  • This issue is addressed in our October 2020 APSF Newsletter
  • APSF has supported 3 research grants on this issue in the past 5 years

Advisory Group:

Chair(s): Ryan Field, MD; Jeffrey Huang, MD
Members: Tong J (TJ) Gan, MD, MBA, MHS, FRCA; Steven J. Barker, PhD, MD; Jeanna Blitz, MD; Natalie Moreland, MD; Ryan Field, MD; Gary Latson , MD; Ashish Khanna, MD; Lena Scotto, MD; Arney Abcejo, MD; Nathanial Bailey, MD; Miles Berger, MD; Scott Plunkett, CAA; Jeffrey Huang, MD; Abbas Al-Qamari, MD; Michelle Humeidan, MD, PhD; Emily Methangkool, MD; Faiza Khan, MD

APSF Activities:

  • This issue has been addressed in 11 articles in the APSF Newsletter since 2016
  • APSF has supported one research grant on this issue in the past 5 years
  • APSF supports ongoing efforts in the U.S. Congress, Joint Commission, and regulatory agencies to promote postoperative monitoring of patients who have received opioids

Advisory Group:

Chair(s): Ken Johnson, MD; Christina Hayhurst, MD
Members: Steven J. Barker, PhD, MD; Erin Manning, MD, PhD; Lisa Einhorn, MD; Joe Pergolizzi, MD; Sesh Mudumbai, MD; Amy Scroggin, CAA; Mark Bendel, MD; Oludare (Dare) (Dare) O. Olatoye, MD; Tori Sutherland, MD; Peter Barelka, MD; Crystal Parrish, NP; Tom Baribeault, CRNA; Keith Morrison; Marilin Wong, PharmD, BCPS, DPLA; Ryan Swinney, MD, MBA

  1. Drug effects
  2. Labeling issues
  3. Shortages
  4. Technology issues (e.g., barcoding, RFID)
  5. Processes for avoiding and detecting errors

2022 APSF Medication Safety Patient Safety Priority Group Recommendations:

  1. The APSF should optimize the use of prefilled syringes and pre-prepared infusions to reduce chance for dilution/labeling errors and potentially minimize waste
  2. The APSF should implement point of care electronic medication scanning for medication checks and clinical decision support prior to medication administration, with auditory (spoken) and displayed medication name, alerts and other critical information
  3. The APSF should work with regulatory bodies and manufacturers to standardize medication vials and distinguish medications by class with color coded labels to reduce errors
  4. The APSF should recommend the use of standard concentrations of medications across patient care areas (e.g., emergency department, ICU, perioperative environments)
  5. The APSF should develop online resource highlighting best medication safety practices (toolbox, checklists, whitepapers, etc.) tailored for anesthesia professionals who practice in facilities with fewer resources than large health systems or academic institutions, such as surgery centers, office-based settings, and community hospitals

APSF Activities:

  • The 2018 APSF Stoelting Conference and 2024 APSF Stoelting Conference was dedicated to this topic
  • APSF presented panels at the 2019 ASA and New York State Society of Anesthesiologists’ annual meetings
  • Multiple APSF Newsletter articles have been published on this issue in 2020
  • APSF sponsored a Summit in 2021 with the Institute for Safe Medication Practices

Advisory Group:

Chair(s): Elizabeth Rebello, MD; Tricia Meyer, PharmD
Members: Brad Taicher, DO, MBA; Amanda Esposito, CAA; Russell McAllister, MD; Rodrigo Daly-Guris, MD; Rachel Wang, MD; Paul Lefebvre, JD; Gwen Volpe, RPh, LSSBB, FASHP; Allison Doney, MHA; Lauren Partyka, MD; Jennifer Stever, CAA; Max B. Kelz, MD, PhD; Taizoon Dhoon, MD; Edward (Ed) A. Maratea, Jr., MD; Amy Pearson, MD; Alan Merry, MD; Karen Nanji, MD; Cindy West, DNP, MBA, CRNA; Fay Horng, MD; Dan Lovinaria, CRNA; Rick Botney, MD; Amanda Milburn, MD; Leo Tabayoyong, PharmD; Aubrey Samost-Williams, MD

APSF Activities:

Advisory Group:

Chair(s): Randy Loftus, MD; Jonathan Charnin, MD
Members: Raquel Bartz, MD; Melanie Hollidge, MD, PhD; Michelle Beam, DO, MBA, FASA; Desiree Chappell, CRNA; Jonathan Tan, MD; Rich Beers, MD; Sara McMannus, BSN; Brendan Wanta, MD; Caitlin Bissell