Improving patient safety seems so simple since we all share, to various degrees, the desire to help our patients—to guide, escort, and usher them through the perils that come with surgeries and other procedures. APSF’s vision that “no patient shall be harmed by anesthesia” is clear. Yet why is improving perioperative patient safety so difficult?
For more than a decade, the APSF has used consensus conferences to identify important patient safety issues in anesthesia care (Table 1). The recommendations from those conferences (Table 2) have been based on strong science and have been formatted to be logical, reasonable, and actionable. A close review of these recommendations seems to support the first two of these assessments; they appear logical and reasonable. However, they have not been uniformly, and certainly not readily, actionable. Broad implementation of these recommendations would likely have improved the perioperative safety of countless patients.
Table 1. APSF Consensus Conferences 2001–2018
|APSF Stoelting Conferences|
|2018||Perioperative Medication Safety: Advancing Best Practices|
|2017||Perioperative Handoffs: Achieving Consensus on How to Get it Right|
|APSF Consensus Conferences|
|2016||Distractions in the Anesthesia Work Environment: Impact on Patient Safety|
|2015||Implementing and Using Emergency Manuals and Checklists to Improve Patient Safety|
|2014||Patient Safety and the Perioperative Surgical Home (PSH)|
|2013||Anesthesia Professionals and the Use of Advanced Medical Technologies: Recommendations for Education, Training, and Documentation|
|2012||Perioperative Visual Loss: Who is at risk, What should we tell patients preoperatively, and How should we manage their intraoperative care?|
|2011||Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period|
|2010||Medication Safety in the Operating Room: Time for a New Paradigm|
|2009||Cerebral Perfusion Pressure and the Beach Chair Position|
|2008||Medication Safety and Its Impact on Patient Safety|
|2007||Improving Training in Advanced Anesthesia Technology: Ensuring Patient Safety|
|2006||Patient-Controlled Analgesia and Opioid-Induced Ventilatory Depression: Recognition and Prevention|
|2005||Carbon Dioxide Desiccation|
|2004||The Long-Term Impact of Anesthesia on Patient Outcomes (and a second one) Ensuring Patient Safety By Requiring the Use of Audible Alarms|
|2003||Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period|
|2002||Advancing the Use of Anesthesia Information Systems to Improve Patient Safety|
|2001||The Impact of Production Pressure on Anesthesia Patient Safety|
Beginning with the September 2018 APSF’s Stoelting Conference on Medication Safety, the foundation will more vigorously pursue implementation of the recommendations that come from the APSF’s annual consensus conferences on patient safety. For this year’s conference on medication safety, the recommendations focus on changes that address safety issues related to drugs and their administration. The specific recommendations of the conference are found in Table 2. Teams for each of the four major categories have provided an implementation plan for each recommendation. APSF has prioritized these and will now provide the resources needed to move them forward. We will engage with all of the appropriate stakeholders as we address these issues.
Table 2. APSF’s Medication Safety Recommendations 2018
|Drug Safety: Identify and promote potentially safer anesthetics
Drug Shortages: Share information, simplify ordering, and establish contingency plans
Reducing Drug Administration Errors: Standardize procedures and doses, carefully document administration, and simplify preparation
Standardization and Innovation: Collaborate across specialties and establish consensus for refined standards
APSF Will Take “Action” On Implementing Safety Recommendations From APSF Consensus Conferences
Our goal is to develop and then support implementation plans for perioperative patient safety that are actionable—the key being “action.” Actions that can improve perioperative patient safety may take many forms, including:
- Improved and expanded dissemination of information about safety issues
- Increased and targeted support for research that generates new knowledge on priority patient safety issues
- Strong collaborations with professional societies, industries, and regulatory agencies to support implementation of perioperative patient safety initiatives
True to our heritage, APSF will be relentless in pursuing actions that improve perioperative patient safety. We look forward to working with all of you on this noble quest.
Dr. Mark Warner is currently President of the APSF and the Annenberg Professor of Anesthesiology, Mayo Clinic, Rochester, MN.
Dr. Warner has no disclosures with regards to the content of the article.