Professor John Senders has been commissioned by the APSF to analyze data from the Australian Incident Monitoring Study. The AIMS is a collection of 2,000 anesthesia-related critical events reported from throughout Australia. A set of 21 articles in a recent symposium issue of Anesthesia and Critical Care described various aspects of the database.(1) It has been learned, for instance, that hypoxic events discovered by oximetry most often arise from endobronchial intubation (2) and that capnography ranked second after oximetry as the monitor most likely to detect an event during general anesthesia.(3) From 19 cases of air embolism, a set of maneuvers was identified as being most effective for treating air embolism. (4) In 58% of 85 cardiac arrests, a clear anesthetic-related cause was identified. (5) The study examined numerous other issues, e.g., applications and limitations of blood pressure monitoring, patient awareness, problems occurring before induction. This extensive AIMS report is a gold mine of information about anesthesia safety. A summary of the AIMS study recently appeared in the Newsletter of the Society for Technology in Anesthesia and will be reprinted in an upcoming issue of the APSF Newsletter.

Goal is Reporting Form

Dr. Senders will be reviewing the AIMS data with the objective of creating an instrument for potential use in an Anesthesia Safety Reporting System in the US, modeled after the system for reporting aviation near misses (ASRS Aviation Safety Reporting System). It is expected that much can be learned from the AIMS data and techniques. A major emphasis of a US Anesthesia Safety Reporting System would include feedback to the clinical community, probably via the APSF Newsletter. The basis for that has already been established in the feature “In My Experience.” Dr. Senders has published extensively on human error and human performance. His book, Human Error: Causes, Prediction and Reduction’ is particularly useful in the anesthesia domain. His eclectic interests and experience in studying and developing concepts of human performance should provide fresh insights to similar problems in anesthesia.

Dr. Cooper, Mass. General Hospital, Boston, is on the APSF Executive Committee.

References

1. Webb RK, Currie M, Morgan CA, Williamson JA, Mackay P, Russell WJ and Runciman WB: The Australian incident monitoring study: An analysis of 2,000 reports. Anaesth Intens Care 21:520-529,1993

2. Runciman WB, Webb RK, Barker L and Currie M: The pulse oximeter: Applications and limitations: An analysis of 2,000 incident reports. Anaesth Intens Care 21:543-550,1993

3. Webb RK, Van der Walt JH, Runciman WB, et al: Which monitor? An analysis of 2,000 incident reports. Anaesth Intens Care 21:529-542,1993

3. Williamson JA, Webb RK and Russell WJ, Runciman WB,: Air embolism: An analysis of 2,000 incident reports. Anaesth Intens Care 21:638-641,1993

4. Morgan C, Webb RK, Cockings J and Williamson JA: Cardiac arrest: An analysis of 2,000 incident reports. Anaesth Intens Care 21:626-637,1993

5. Senders JW and Moray NP: Human Error: Causes, Prediction and Reduction, Lawrence Erlbaum Associates, London, 1991