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Chapter: Clinical Anesthesiology: Perioperative & Critical Care Medicine: Safety, Quality, & Performance Improvement

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Patient Safety Issues

As a profession, anesthesiology has spearheaded efforts to improve patient safety.

PATIENT SAFETY ISSUES

 

As a profession, anesthesiology has spearheaded efforts to improve patient safety. Some of the first studies to evaluate safety of care focused on pro-vision and sequelae of anesthesia. When spinal anesthesia was virtually abandoned in the United Kingdom (after two patients developed paraple-gia following administration of spinal anesthet-ics), Drs Robert Dripps and Leroy Vandam helped prevent this technique from being abandoned in North America by carefully reporting outcomes of 10,098 patients who received spinal anesthe-sia. They determined that only one patient (who proved to have a previously undiagnosed spinal meningioma) developed severe, long-term neuro-logical sequelae.

After halothane was introduced into clinical practice in 1954, concerns arose about whether it might be associated with an increased risk of hepatic injury. The National Halothane Study, per-haps the first clinical outcomes study to be per-formed (long before the term outcomes research gained widespread use), demonstrated the remark-able safety of the then relatively new agent com-pared with the alternatives. It failed, however, to settle the question of whether “halothane hepatitis” actually existed.In the 1980s, anesthesiologists were recog-nized for being the first medical specialiststo adopt mandatory safety-related clinical practice guidelines. Adoption of these guidelines was not without controversy, given that for the first time the American Society of Anesthesiologists (ASA) was “dictating” how physicians could practice. The effort resulted in standards for basic monitoring during general anesthesia that included detection of carbon dioxide in exhaled gas. Adoption of these standards was associated with a reduction in the number of patients suffering brain damage or death secondary to ventilation mishaps during general anesthesia. A fortunate associated result was that the cost of medical liability insurance coverage also declined.

In 1984, Ellison Pierce, president of the ASA, created its Patient Safety and Risk Management Committee. The Anesthesia Patient Safety Founda-tion (APSF), which celebrated its 25th anniversary in 2011, was also Dr Pierce’s creation. The APSF continues to spearhead efforts to make anesthe-sia and perioperative care safer for patients and practitioners. Similarly, through its guidelines, statements, advisories, and practice parameters, the ASA continues to promote safety and provide guidance to clinicians. As Dr Pierce noted, “Patient safety is not a fad. It is not a preoccupation of the past. It is not an objective that has been fulfilled or a reflection of a problem that has been solved. Patient safety is an ongoing necessity. It must be sustained by research, training, and daily application in the workplace.”

Meanwhile, other specialties of medicine began to place greater emphasis on quality and safety.In 1999 the Institute of Medicine (IOM) of the (U.S.) National Academy of Sciences summarized available safety information in a report enti-tled To Err is Human: Building a Safer Healthcare System. Th at document highlighted many opportu-nities for improved quality and safety in the Ameri-can health care system. A subsequent IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century, explored the way that variation in medical practice reduced quality and safety of health care system. More recently, the Institute for Healthcare Improvement has been “motivating and building the will for change; identifying and testing new models of care in partnership with both patients and health care professionals; and ensuring the broadest possible adoption of best practices and effective innovations,” as described on its web site.

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