As president of the Anesthesia Patient Safety Foundation (APSF), it is my privilege to report annually on the activities of the foundation during the past calendar year. As in my previous annual reports, I believe it is important to recognize that the APSF, as an advocacy group, does not write standards. Recommendations developed and promulgated by the APSF are intended to assist professionals who are responsible for making health care decisions. Recommendations promulgated by the APSF focus on minimizing the risk to individual patients for rare adverse events rather than necessarily on practices that balance all aspects of population health quality and cost. The APSF does not intend for these recommendations to be standards, guidelines, or clinical requirements nor does application of these recommendations guarantee any specific outcome. Furthermore, these recommendations may be adopted, modified, or rejected according to clinical needs and restraints. The APSF recognizes that these recommendations are subject to revision as warranted by the evolution of medical knowledge, technology, and practice.
A highlight of the annual meeting of the American Society of Anesthesiologists in San Francisco in October 2013 was the Ellison C. Pierce, Jr., MD, Patient Safety Memorial lecture delivered by Alan F. Merry, MBChB. Dr. Merry’s topic was “Toward Patient Safety in Anesthesia—Let the Journey Continue.” This named lectureship continues to be part of the annual ASA meeting thus providing sustained recognition for the vision and contributions to anesthesia patient safety made by Dr. Pierce as the founding president of the APSF. The annual APSF Board of Directors Workshop held on October 12, 2013, was moderated by David M. Gaba, MD, and entitled “Should anesthesia incidents be investigated as they are in other high-risk industries?”
The APSF was pleased to congratulate Jeffrey B. Cooper, PhD for his well-deserved selection as the 2012 recipient of the prestigious ASA Distinguished Service Award. Dr. Cooper was a founding member of the APSF Executive Committee in 1985 and has continued to lead anesthesia patient safety efforts during his illustrious career (see p.56 of this issue).
The APSF is pleased to announce the availability of complimentary copies of the following educational DVDs (visit the APSF website for details, dev2.apsf.org):
- Opioid-Induced Ventilatory Impairment (OIVI): Time for a Change in the Monitoring Strategy for Postoperative PCA Patients (Executive Summary, 7 minutes)
- Perioperative Visual Loss (POVL): Risk Factors and Evolving Management Strategies (Executive Summary, 10 minutes)
- APSF Presents Simulated Informed Consent Scenarios for Patients at Risk for Perioperative Visual Loss (POVL) (18 minutes)
The simulated informed consent scenarios are based on the conclusions of the September 11, 2012, APSF-sponsored multispecialty conference that “the remote risk of blindness should be part of the informed consent process” for patients at risk for POVL.
Residual Muscle Relaxant-Induced Weakness in the Postoperative Period: Is It a Patient Safety Issue?
The APSF conducted a survey of anesthesia professionals’ opinions regarding the patient safety importance of residual muscle relaxant-induced weakness in the postoperative period. The results of this survey are reported starting on page 49 of this issue.
Anesthesia Professionals and the Use of Advanced Medical Technologies: Recommendations for Education, Training, and Documentation
The APSF sponsored a conference on Wednesday, September 18, 2013 (Royal Palms Resort and Spa, Phoenix, AZ), to address the safe use of advanced medical technology by anesthesia professionals. The conference engaged all stakeholders (anesthesia professionals, technology manufacturers, accrediting and regulatory agencies, professional technology organizations, insurers, hospital administrators, risk managers) to discuss and refine the existing APSF Committee on Technology’s Advanced Medical Technology Training document (https://dev2.apsf.org/announcements.php?id=27).
Using an audience response system, 60% of the 94 attendees described themselves as anesthesia professionals, 97% of the attendees believed the logic was compelling to require confirmation of competence before using advanced medical technology despite a paucity of supporting literature, 93% viewed standardization of technology as important for safety, 65% of the respondents viewed the “traditional in-service model” (occurs when equipment installed, voluntary, offered during clinical work hours) as “inadequate (cannot be fixed and needs to be replaced with new concepts/technology such as e-learning modules, hands on simulator sessions and individual downloadable apps), and 91% of attendees concluded the APSF should encourage anesthesia professional societies to promote adoption of training requirements on the use of advanced medical technology.
Patient Safety and the Perioperative Surgical Home (PSH)
The APSF will hold a consensus conference on this topic on Wednesday, September 3, 2014 (Royal Palms Resort and Spa, Phoenix, AZ). The APSF believes that the model envisioned by the PSH will present opportunities for patient safety innovations. The goals of this 1-day conference will include establishing a better understanding of the PSH concept and how its implementation could facilitate patient safety initiatives. Those interested in attending the conference are encouraged to contact Dr. Stoelting ([email protected]) for registration information.
The APSF Committee on Scientific Evaluation chaired by Steven K. Howard, MD, received 45 grant applications in 2013. In October 2013, the committee recommended funding the following 4 research awards totaling $543,461 to begin in January 2014.
In addition, the APSF will continue its support of the APSF Safety Scientist Career Development Award (SSCDA) ($150,000.00 over 2 years) beginning in July 2014. The APSF will also award a grant of up to $200,000 to begin in July 2014 to evaluate the “implementation and performance” of the APSF Pre-Induction Patient Safety (PIPS) checklist.
The APSF is the largest private funding source for anesthesia patient safety research in the world. Since the inception of the APSF grant program 727 grant applications have been received by the APSF. When the first grants were funded in 1987, funding for anesthesia patient safety was virtually unknown. Since 1987, the APSF has awarded 100 grants for almost $9 million. The impact of these research grants is more far-reaching than the absolute number of grants and total dollars, as APSF-sponsored research has led to other investigations and the development of a cadre of anesthesia patient safety investigators.
The APSF Newsletter continues its role as a vehicle for rapid dissemination of anesthesia patient safety information with Robert C. Morell, MD, and Lorri A. Lee, MD, as co-editors. The
APSF Newsletter is provided as a member benefit by the ASA, American Association of Nurse Anesthetists (AANA), American Association of Anesthesiologists Assistants (AAAA), American Society of Anesthesia Technologists and Technicians (ASATT), American Society of PeriAnesthesia Nurses (ASPAN), American Society of Dentist Anesthesiologists (ASDA), American Dental Society of Anesthesia (ADSA), and the American Association of Oral Maxillofacial Surgeons (AAOMS) with a resulting circulation of 107,515. In addition to the electronic version of the
APSF Newsletter, a hardcopy is mailed to all members of the ASA, AANA, AAAA, ASPAN, and ASDA.
The “Question and Answers” and “Dear SIRS” (Safety Information Response System) columns in the APSF Newsletter provide rapid dissemination of safety issues related to anesthesia equipment in response to questions from readers. These columns are coordinated by Drs. A. William Paulsen (chair, APSF Committee on Technology) and Robert C. Morell (co-editor, APSF Newsletter). The value of industry to anesthesia patient safety is reflected by these columns.
The APSF website design and appearance (dev2.apsf.org) continues under the direction of APSF Executive Vice President George A. Schapiro. The APSF website includes a monthly poll question related to anesthesia patient safety issues. The poll question is coordinated by Timothy N. Harwood, MD, a member of the APSF Committee on Education and Training chaired by Richard C. Prielipp, MD. Online donations to APSF are possible via the website.
Sorin J. Brull, MD, continues as the Patient Safety Section editor for Anesthesia & Analgesia.
The APSF sponsored a panel entitled “Anesthetic Toxicity in Infants” at the May 2013 annual congress of the International Anesthesia Research Society. The panel was moderated by Richard C. Prielipp, MD, chair, APSF Committee on Education and Training.
Prevention and Management of Operating Room Fires
To date more than 6,000 individual requests for the complimentary copy of the Prevention and Management of Operating Room Fires DVD (https://dev2.apsf.org/resources_video.php) have been received. In an effort to increase awareness for the potential of surgical fires in at risk patients, the APSF published a “Fire Prevention Algorithm” in the Winter 2012 issue of the
APSF Newsletter (https://dev2.apsf.org/newsletters/html/2012/winter/index.htm). The goal of the “APSF Fire Prevention Algorithm” to increase awareness of the risk of operating room fires was endorsed by ASA, AAAA, AANA, ASATT, American College of Surgeons, ASPAN, Association of periOperative Registered Nurses, ECRI Institute, Food and Drug Administration Safe Use Initiative, National Patient Safety Foundation, and The Joint Commission.
Medication Safety in the Operating Room
To date more than 2,000 individual requests for the complimentary copy of the 18-minute educational DVD entitled “Medication Safety in the Operating Room: Time for a New Paradigm” (https://dev2.apsf.org/resources_video2.php) have been received.
Financial support to the APSF from individuals, specialty and components societies, and corporate partners in 2013 has been most gratifying. This sustained level of financial support makes possible the undertaking of new safety initiatives, the continuation of existing safety initiatives, and funding for anesthesia patient safety research. The level of research support is particularly dependent on the level of financial support received.
The link for online donations to the APSF is https://dev2.apsf.org/donate.php. Contributions may also be mailed to the Anesthesia Patient Safety Foundation, 515 North Northwest Highway, Park Ridge, IL, 60068.
The APSF extends it condolences to the family, friends, and colleagues of Ephraim (“Rick”) S. Siker, MD, who passed away on June 21, 2013 (https://dev2.apsf.org/newsletters/pdf/Fall2013.pdf). Dr. Siker was a past president of the ASA and a founding member of the APSF Executive Committee, retiring from the APSF Board of Directors in 2003 after 18 years of service. Dr. Siker was a tireless advocate for patient safety, mixing his passion for the foundation’s mission that “no patient shall be harmed by anesthesia” with wit and wisdom that only he could provide.
The APSF is also saddened to learn of the passing of Jerod Loeb, PhD, member of the APSF Board of Directors. Our condolences are extended to Dr. Loeb’s family.
The APSF thanks retiring board directors, Patricia A. Kapur, MD, and Alexander A. Hannenberg, MD, and welcomes new directors, Daniel J. Cole, MD, and Jerry A. Cohen.
At the annual meeting of the APSF Board of Directors in October 2013, Steven R. Sanford, JD, was elected as a member-at-large to the APSF Executive Committee and Robert J. White, Covidien, became vice president.
As in the previous annual report, I wish to reiterate the desire of the APSF Executive Committee to provide a broad-based consensus on anesthesia patient safety issues. We welcome the comments and suggestions from all those who participate in the common goal of making anesthesia a safe experience. There remains much still to accomplish and everyone’s participation and contributions are important.
Best wishes for a prosperous and rewarding year 2014.
Robert K. Stoelting, MD President