Anesthesiology: An Evolution in Safety

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By Mark A. Warner, MD

When the first ambulatory surgical center was opened in 1970, the risk of a relatively healthy patient dying within 24 hours of an anesthetic and surgical procedure was approximately 1 in 10,000 cases. In the subsequent four decades, that risk has decreased at least 25-fold; the best estimates now suggesting that the frequency is 1 in 250,000 cases. This improvement in surgical patient safety is one of the great achievements in modern medicine.

Dramatic? Absolutely! As good as it can get? Absolutely not!

There are many reasons that the safety of surgical patients has improved so steadily throughout this time period. Surgical procedures have become less invasive, and many surgical techniques now result in much less blood loss and tissue trauma and fewer postoperative complications. The drugs used intraoperatively for anesthesia, postoperatively for analgesia, and perioperatively for infection prevention and treatment have improved remarkably. However, one significant effort stands out for its contribution to better patient safety – a major effort of the American Society of Anesthesiologists (ASA) to standardize anesthesia care and patient monitoring. The contributions of the society to patient safety were noted by the Institute of Medicine in its 2000 treatise, “To Err is Human: Building a Safer Health System." In fact, the ASA was the only specialty organization recognized in this treatise for its success in improving patient safety.

Patient Safety and Anesthesiology

How safe is ambulatory surgery? The risk improvement in the two decades since the initial 1970 ambulatory surgical center was remarkable. By 1993, a large study published in the Journal of the American Medical Association found that it was safer to undergo outpatient surgery than it was to travel to and from the ambulatory surgical center by car. Improvements in the successive years have made anesthesia for these patients even better. The ASA led the current patient safety initiative in the United States when it instituted the Anesthesia Patient Safety Foundation (APSF) in 1985. This initiative and its high profile patient-safety movement resulted in standardized practices that required the use of pulse oximetry and end endtidal carbon dioxide monitoring for anesthetized patients. These requirements markedly reduced the frequency of anoxic brain injury and other major complications. The efforts of the APSF to share patient-safety information and best practices with all anesthesia providers, equipment manufacturers and pharmaceutical companies have been well recognized. For example, the National Patient Safety Foundation, started in 1997, was modeled on the APSF.

The APSF is now in its 25th year. The organization currently sponsors major workshops in which key stakeholders meet to share ideas on specific topics (e.g., medication errors and fire safety). Government agencies, manufacturers, surgeons, anesthesiologists, other anesthesia providers, nurses and patients gather, review problems, project innovative processes, debate merits and develop changes that will likely result in safety improvements. The APSF is primarily financed by contributions from the ASA and unrestricted grants from drug and equipment companies, with each dedicated to reducing complications in surgical patients. No commercial entity directly benefits financially from support of the APSF. Patient safety via APSF is a true altruistic endeavor.

The Importance of Patient Safety

With all of these improvements, why emphasize patient safety? Isn’t it already safe?

Let’s use an example to illustrate why we all strive to make further improvements. Literally hundreds of patients in the U.S. either die or suffer anoxic brain injury annually from postoperative respiratory depression. This problem is solvable: (1) we know many of the patient characteristics and surgical and anesthetic risk factors associated with postoperative respiratory depression; (2) we know that opioid analgesics play a role in nearly all instances of postoperative respiratory arrest; and (3) we have technologies that can detect postoperative respiratory depression. Despite this knowledge, we still have patients dying or significantly impaired by this problem. Sadly, we are missing the union of forces that is necessary to address it.

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