The Anesthesia Patient Safety Foundation has awarded a grant to the Society for Pediatric Anesthesia (SPA) to assist in the development of “Wake up Safe,” a quality improvement initiative to collect and analyze causes of adverse outcomes that occur during anesthesia in children in the United States.
The beginning phase involves representatives from 10 major pediatric institutions. Among these are Children’s Hospital Boston, the Children’s Hospital of New York, Children’s Hospital and Regional Medical Center (Seattle, WA), John Hopkins Children’s Center, Texas Children’s Hospital, and Vanderbilt Children’s Hospital, in association with the SPA. The group is developing a standard method for Event Analysis to assess serious perioperative adverse events, which can be used as part of the peer review process in each hospital. Analysis of the data from these events will permit the SPA “Wake up Safe” steering group to make recommendations for practice changes designed to reduce the frequency of these untoward events and improve patient safety.
Although great strides have been made in safety since the discovery of anesthesia 160 years ago, patients continue to experience harm related to anesthesia and surgical care. Despite the millions of anesthetics delivered each year to children and the many years that anesthesia has been used in children, the incidence and etiology of these serious events remain uncertain and not well studied, in large part because these events are relatively rare today and an integrated system to report and analyze them does not exist. The SPA Wake up Safe Initiative should allow us to learn from the adverse events to improve care. After the initial phase, the goal is to make the Event Analysis and the related learning opportunity available to all children’s hospitals and pediatric anesthesia programs around the country.
Initially the events to be studied include death, cardiac arrest, serious bodily injury, unanticipated major escalation of care, surgery on the wrong patient or body part, fire, awareness under anesthesia, and the medication error resulting in serious injury. As the participating institutions and the Wake up Safe steering committee gather experience, additional events and other expected and unexpected outcomes will be added.
The Society for Pediatric Anesthesia is the largest professional group for Pediatric Anesthesiologists in the United States. The mission of the SPA is to “foster quality anesthesia and perioperative care, and to alleviate pain in children.” The Society has approximately 1700 active members in the United States, including most pediatric anesthesiologists in the country, as well as members from other countries.