In October 1984, the International Symposium on Preventable Anesthetic Morbidity and Mortality (ISPAMM) met in Boston for the first time, with some 50 participants present from five English speaking nations and Belgium. It is interesting to me to note that many of them as well as the corporate sponsors are alive and still supporting patient safety. At that meeting the Anesthesia Patient Safety Foundation (APSF) was conceived. An organizational meeting for the APSF followed in October 1985 at the ASA annual meeting in San Francisco. Below are excerpts from the Minutes of ISPAMM,¹ which clearly allow us to discern the enormous strides made in patient safety since those primitive days as well as areas of failure. In future issues of this Newsletter we will examine minutes of the early days of APSF.

“Participants, identified by work or interest in the field, shared information and provided the forum for discussions. The ultimate purpose of the meeting was to consider methods for reducing anesthesia morbidity and mortality….

“Opening presentations dealt with a review of existing data, which unfortunately relied heavily upon anecdotal reporting and retrospective judgments rather than upon prospective case finding…. Presentations of specific topics followed by workshops related to these topics constituted the structure of the symposium… workshops included monitoring requirements, equipment design, techniques and priorities of data collection, physician training, education, and competence and quality assurance….

“A recurrent theme was the frequent inability to document the relationship between anesthesia and undesirable outcome except in instances where the cause may be obvious and known, such as, a drug error or ventilator disconnect, or esophageal intubation. In many instances the relationship depends on circumstantial evidence, which then requires that a judgment be rendered…. Another uneasy and unanswered question was whether a brain-dead patient maintained on life support systems constituted morbidity or mortality, while another, related to the title of the symposium, asked if major morbidity and mortality were not always preventable…. A case cited to illustrate the issue concerned a death following a thiopental induction in an elderly, acutely ill patient. Does one ascribe this to overdose or wrong drug, or hypovolemia, or failure of an intervention, or none of these? Is this preventable mortality?…

“The workshop on monitoring during anesthesia generated heated discussions, and in no other area were the differences between national practice patterns more in evidence. Clearly, the availability of a plethora of monitoring devices and the malpractice climate in the United States have created pressures for their use…. An attempt to list monitors in terms of their importance to optimal anesthesia care elicited little agreement, primarily because their contribution to care never has been measured. The need for such study was apparent, since any contribution must be weighed against potential downside risks of decreased vigilance, equipment failure, and erroneous information. A clearly expressed concern, and there was ready consensus, was the legal implications of establishing a standard of minimal acceptable monitoring during anesthesia, particularly in the absence of supporting data….

“The most important aspects of this symposium were that it was held, that the problems discussed had international relevance, that there is an extraordinary dearth of data to apply to the questions and the need to stimulate their collection.”

References

1. Keats AS, Siker ES: International Symposium on Preventable Anesthetic Morbidity and Mortality, Boston, Massachusetts, October 8-10, 1984 (report). Anesthesiology 1985;63:349-50.

Dr. Pierce is the Executive Director and a founding member of the the Anesthesia Patient Safety Foundation.

Research Grant Applications Solicited by APSF The Anesthesia Patient Safety Foundation announces the deadline of June 17, 2002, for receipt of applications for research grants to start January 1, 2003. Note: Grants are limited to the total amount of $65,000, cannot include indirect costs, and must be completed within 2 years. Highest priority is given to studies that concern problems of anesthesia for relatively healthy patients or are broadly applicable and that promise improved methods of patient safety with a defined and direct path to implementation into clinical care. Areas of research interest include, but are not limited to: new clinical methods for prevention and/or early diagnosis of mishaps, evaluation of new and/or re-evaluation of old technologies for prevention and diagnosis, identification of predictors of patients and anesthetists at increased risk for mishaps, development of innovative methods for study of low-frequency events, methods for measurement of cost effectiveness of techniques designed to increase patient safety, and innovative methods of education and training in safety. Guidelines describing the scope of the grant program and the application format may be obtained from the Anesthesia Patient Safety Foundation, Executive Office, 4246 Colonial Park Drive, Pittsburgh, PA 15227-2621. Also, the guidelines for grant application can be found on and downloaded from the APSF Web Page: dev2.apsf.org. Awards will be announced at the annual meeting of the APSF on October 12, 2002 in Orlando, Florida.