Anesthesia Patient Safety Foundation Research Articles

"Safety Monitoring" Behavior and Technology: Reflections From the Anesthesia Patient Safety Foundation 2023 E. C. Pierce, MD, Memorial Lecture.

"Safety Monitoring" Behavior and Technology: Reflections From the Anesthesia Patient Safety Foundation 2023 E. C. Pierce, MD, Memorial Lecture.

Depth of anesthesia monitoring: an argument for its use for patient safety.

There have been significant advancements in depth of anesthesia (DoA) technology. The Anesthesia Patient Safety Foundation recently published recommendations to use a DoA monitor in specific patient populations receiving general anesthesia. However, the universal use of DoA monitoring is not yet accepted. This review explores the current state of DoA monitors and their potential impact on patient safety. We reviewed the current evidence for using a DoA monitor and its potential role in preventing awareness and preserving brain health by decreasing the incidence of postoperative delirium and postoperative cognitive dysfunction or decline (POCD). We also explored the evidence for use of DoA monitors in improving postoperative clinical indicators such as organ dysfunction, mortality and length of stay. We discuss the use of DoA monitoring in the pediatric population, as well as highlight the current limitations of DoA monitoring and the path forward. There is evidence that DoA monitoring may decrease the incidence of awareness, postoperative delirium, POCD and improve several postoperative outcomes. In children, DoA monitoring may decrease the incidence of awareness and emergence delirium, but long-term effects are unknown. While there are key limitations to DoA monitoring technology, we argue that DoA monitoring shows great promise in improving patient safety in most, if not all anesthetic populations.

Perioperative Patients With Hemodynamic Instability: Consensus Recommendations of the Anesthesia Patient Safety Foundation. Call for an Additional Monitor.

Perioperative Patients With Hemodynamic Instability: Consensus Recommendations of the Anesthesia Patient Safety Foundation. Call for an Additional Monitor.

Perioperative Patients With Hemodynamic Instability: Consensus Recommendations of the Anesthesia Patient Safety Foundation.

In November of 2022, the Anesthesia Patient Safety Foundation held a Consensus Conference on Hemodynamic Instability with invited experts. The objective was to review the science and use expert consensus to produce best practice recommendations to address the issue of perioperative hemodynamic instability. After expert presentations, a modified Delphi process using discussions, voting, and feedback resulted in 17 recommendations regarding advancing the perioperative care of the patient at risk of, or with, hemodynamic instability. There were 17 high-level recommendations. These recommendations related to the following 7 domains: Current Knowledge (5 statements); Preventing Hemodynamic Instability-Related Harm During All Phases of Care (4 statements); Data-Driven Quality Improvement (3 statements); Informing Patients (2 statements); The Importance of Technology (1 statement); Launch a National Campaign (1 statement); and Advancing the Science (1 statement). A summary of the recommendations is presented in Table 1 .

Consensus Recommendations for the Safe Conduct of Nonoperating Room Anesthesia: A Meeting Report From the 2022 Stoelting Conference of the Anesthesia Patient Safety Foundation.

Beard, John MD*; Methangkool, Emily MD, MPH†; Angus, Shane CAA, MSA‡; Urman, Richard D. MD, MBA§; Cole, Daniel J. MD† Author Information

Quality of Life After Critical Illness.

1 Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA. 2 Harvard Medical School, Boston, MA. 3 Ariadne Labs, Boston, MA. *See also p. 632. The views expressed in this article are those of the authors and do not necessarily represent the views of others. Support was provided solely from institutional sources. Dr. Arriaga is the recipient of: 1) a mentored research training grant from the Anesthesia Patient Safety Foundation (APSF) and the Foundation for Anesthesia Education and Research (FAER) and 2) a Career Development Award from the Center for Diversity and Inclusion of the Brigham and Women’s Hospital. He is also a member of the Patient Safety Editorial Board for the American Society of Anesthesiologists and Question Editor/Examiner for the American Board of Anesthesiology, where he receives a stipend for work that is otherwise done in a volunteer capacity. He received funding from the American Society of Anesthesiologists Patient Safety Editorial Board, the American Board of Anesthesiology, the Minority Faculty Career Development Award from the Center for Diversity and Inclusion of the Brigham and Women’s Hospital, the APSF, and the FAER. Dr. Allen has disclosed that he does not have any potential conflicts of interest.

Low-Flow Anesthesia...100 Years Later

Anesthesia Patient Safety Foundation| March 2023 Low-Flow Anesthesia...100 Years Later Jeffrey M. Feldman, MD, MSE; Jeffrey M. Feldman, MD, MSE Search for other works by this author on: This Site PubMed Google Scholar Samsun (Sem) Lampotang, PhD, FSSH, FAIMBE Samsun (Sem) Lampotang, PhD, FSSH, FAIMBE Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor March 2023, Vol. 87, 36. https://doi.org/10.1097/01.ASM.0000922056.23891.43 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Jeffrey M. Feldman, Samsun (Sem) Lampotang; Low-Flow Anesthesia...100 Years Later. ASA Monitor 2023; 87:36 doi: https://doi.org/10.1097/01.ASM.0000922056.23891.43 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: fluid flow “The signs of oxygen want and plane of anesthesia as shown by color, muscular phenomena, etc. must be watched constantly...” Ralph Waters, MD, Anesthesia & Analgesia, 1926 One hundred years ago, Dr. Ralph Waters introduced carbon dioxide absorbents to facilitate rebreathing of exhaled anesthetics, and reduce the need for adding fresh gas and anesthetic to the breathing circuit. Advantages included reduced use (cost) of inhaled anesthetics, reduced exposure of the surgical team to anesthetics, since scavenging systems were not used, and better preservation of the patient's temperature and airway humidity. As the quote above from his 1926 article indicates, Dr. Waters was concerned about the safety implications of reducing fresh gas flow, specifically inadequate oxygen and inadequate anesthetic depth (Anesth Analg 1926;5:160-2). With careful clinical observation, Dr. Waters was able to safely practice low-flow anesthesia using a bag-mask type device with an integrated CO2 absorbent. In... You do not currently have access to this content.

Medication safety in pediatric anesthesia: An educational review and a call to action.

Children presenting for anesthesia are at high risk for medication error during their care. In this educational review, we address the rates of medication error in pediatric patients undergoing anesthesia, why they are at higher risk than adults, and why reporting chronically underestimates the number of medication errors incurred during the anesthetic care of children. We also introduce the Anesthesia Patient Safety Foundation and Wake Up Safe, two safety organizations that have led the call to decrease medication errors. We discuss various tools to increase medication safety, as championed by Anesthesia Patient Safety Foundation and Wake Up Safe, including human factors research and highlight a few studies that have evaluated and addressed medication safety in the anesthesia environment.

Preventing Postoperative Respiratory Depression

Safety Tip of the Month| October 2022 Preventing Postoperative Respiratory Depression ASA Monitor October 2022, Vol. 86, 18. https://doi.org/10.1097/01.ASM.0000890052.75873.d9 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Preventing Postoperative Respiratory Depression. ASA Monitor 2022; 86:18 doi: https://doi.org/10.1097/01.ASM.0000890052.75873.d9 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: respiratory depression, opioids The Anesthesia Patient Safety Foundation (APSF) declared that “no patient shall be harmed by opioid-induced respiratory depression (OIRD)” about a decade ago (asamonitor.pub/3JCdDkf). In 2021 alone, more than 100,000 Americans died due to drug overdoses, with around 75% of those deaths due to opioids (asamonitor.pub/3f9RhZi). Postoperative OIRD continues to be a costly and potentially fatal problem (Anesth Analg 2020;131:1012-24). The following three steps are identified as critical for screening, diagnosing, monitoring, and reducing OIRD (Figure) (Anesth Analg 2020;131:1007-11). The incidence of undiagnosed obstructive sleep apnea (OSA) may be as high as 60% (Chest 2016;149:631-8). OSA is a significant predictor of postoperative respiratory complications (Sleep 2008;31:1071-8; Anesthesiology 2014;121:707-18). The Snoring, Tiredness, Observed apnea, high blood Pressure and BMI, Age, Neck circumference, Gender (STOP-Bang) questionnaire is effective in identifying adult patients with OSA at high risk of OIRD (... You do not currently have access to this content.

‘Quality,’ Mediocrity, and Unintended Consequences

Peering Over the Ether Screen| July 2022 ‘Quality,’ Mediocrity, and Unintended Consequences Karen S. Sibert, MD, FASA Karen S. Sibert, MD, FASA Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor July 2022, Vol. 86, 1–11. https://doi.org/10.1097/01.ASM.0000842012.29668.61 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Karen S. Sibert; ‘Quality,’ Mediocrity, and Unintended Consequences. ASA Monitor 2022; 86:1–11 doi: https://doi.org/10.1097/01.ASM.0000842012.29668.61 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: double effect Today's noteworthy definitions, not new but often ignored: In anesthesiology, these precepts should be kept firmly in mind in our attempts to improve “quality.” Anyone who speaks out against measures that are taken under the banner of improving “quality of care” or “patient safety” risks coming across as reckless, heartless, or both. Yet the pursuit of “quality” in health care has a track record of implementing changes and policies that haven't been subjected to any rigorous scientific study, in effect “prioritizing action over evidence” (N Engl J Med 2007;357:608-13). In anesthesiology, we love our gadgets. We especially like gadgets that generate numerical values we can track. It's no wonder that quantitative nerve stimulators measuring thumb movement via acceleromyography are gaining in popularity. They give us a ratio of neuromuscular recovery that we can document and trumpet as evidence of high-quality care, blessed by the Anesthesia Patient Safety Foundation... You do not currently have access to this content.

Making Healthcare Safe: The Story of the Patient Safety Movement

Making Healthcare Safe: The Story of the Patient Safety Movement

Labeled Surgical Caps: A Tool to Improve Perioperative Communication.

Communication in the operating room is enhanced by knowing everyone’s names and roles. This is challenging among different disciplines.1 Name badges can be small, flipped, and concealed by personal protective equipment. A labeled scrub cap may make name and role more readable from a distance (fig.). Role clarity and addressing individuals by name enhance communication, teamwork, and patient safety.2 Role clarity may also promote diversity, equity, and inclusion. For example, women were 20% less likely to be thought of as surgeons by patients.3 In an anesthesiology care team model, role confusion can sometimes be misleading to patients and medical professionals.At our hospital, each team member received several labeled caps to allow for laundering and a clean cap to be worn in the perioperative area. Although there was previous concern regarding head coverings and infection risk, multiple organizations, including the American Society of Anesthesiologists (Schaumburg, Illinois), The Joint Commission (Oakbrook Terrace, Illinois), and surgical and nursing societies, have concluded that there is no association between surgical cap type and surgical site infection.4 Each interprofessional group designated its preferred notation. Physicians chose “Doctor” with full name, whereas nurses preferred “RN” with first name.Individuals have put names on their surgical caps for years. Institutional sponsorship supporting the majority of providers wearing labeled caps represents a culture change enhancing effective team communication. Widespread use of low-cost caps with clearly identifiable names and roles may improve communication, role clarity, provider well-being, and diversity, equity, and inclusion while enhancing patient safety and not increasing risk of surgical site infection.The authors thank Ling Chen, M.S.N., R.N., C.N.O.R. (Interventional Platform Education, Stanford, California), Teresa Roman-Micek, B.S., C.H.S.O.S. (Interventional Platform Education), and Katherine Field, B.A. (Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, School of Medicine, Stanford, California), for their tireless work. They also thank Stanford Hospital and Clinics and the Departments of General Surgery and Anesthesiology, Perioperative and Pain Medicine, for their support in widespread adoption of labeled surgical caps. Photo credit: Chad Howard, R.N., Palo Alto, California.Dr. Goldhaber-Fiebert received an honorarium from the Korean Society of Anesthesiologists (Seoul, Korea) for a talk presented virtually at KoreAnesthesia 2021, which took place in Busan, Korea. She has also received a grant from the Anesthesia Patient Safety Foundation (Rochester, Minnesota). The other authors declare no competing interests.

The Evolution of the Anesthesia Patient Safety Movement in America: Lessons Learned and Considerations to Promote Further Improvement in Patient Safety.

Ellison C. Pierce, Jr., M.D., and a small number of specialty leaders and scientists formed a remarkable, diverse team in the mid-1980s to address a dual crisis: a safety crisis for anesthetized patients and a medical malpractice insurance crisis for anesthesiologists. This cohesive team's efforts led to the formation of the Anesthesia Patient Safety Foundation, the American Society of Anesthesiologists's Committees on Standards of Care and on Patient Safety and Risk Management, and the society's Closed Claims Project. The commonality of leaders and members of the Anesthesia Patient Safety Foundation and American Society of Anesthesiologists initiatives provided the strong coordination needed for their efforts to effect change, introduce standards of care and practice parameters, obtain financial support needed to grow patient safety-oriented new knowledge, integrate industry and other relevant leaders outside of anesthesiology, and involve all anesthesia professions. By implementing successful patient safety initiatives, they promoted the recognition that anesthesiology and patient safety are inextricably linked.

Patient safety education in anesthesia: current state and future directions.

Although patient safety is a core component of education in anesthesiology, approaches to implementation of education programs are less well defined. The goal of this review is to describe the current state of education in anesthesia patient safety and the ideal patient safety curriculum. Anesthesiology has been a pioneer in patient safety for decades, with efforts amongst national organizations, such as the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation to disseminate key standards and guidelines in patient safety. However, few, if any strategies for implementation of a patient safety curriculum in anesthesiology exist. Patient safety education is crucial to the field of anesthesiology, particularly with the advancement of surgical and anesthesia technologies and increasing complexity of patients and procedures. The ideal patient safety curriculum in anesthesiology consists of simulation, adverse event investigation and analysis, and participation in process improvement. Efforts in education must adapt with changing technology, shifts in the way anesthesia care is delivered, and threats to physician wellness. Future efforts in education should harness emerging platforms, such as social media, podcasts, and wikis.

Perioperative Stroke: Comment

THE review article about strokes in surgical patients1 omitted an important, although rare, cause of strokes. Patients undergoing shoulder surgery in the sitting or beach chair position risk a hypotensive/hypoperfusion ischemic stroke because the mean arterial pressure (MAP) in the brain is significantly lower than the cuff blood pressure measured at the arm (heart level). This intraoperative event is especially devastating because it occurs in relatively healthy patients who usually have no risk factors for stroke; they are simply undergoing shoulder surgery to improve their quality of life.How does this happen? The beach chair position sits the patient at about 70 degrees. The brainstem MAP is about 20 to 40 mmHg lower (depending on the patient’s height) than the measured cuff blood pressure. The additional height to the cerebral cortex lowers brain MAP another 6 to 9 mmHg. Every inch of vertical height from the blood pressure cuff’s position on the arm to the brain reduces MAP 2 mmHg.2 This principle was well understood when anesthetizing neurosurgical patients for sitting craniotomies decades ago; appropriate adjustments were made to maintain adequate MAPs in the brain.3 This correction seems to have been forgotten or no longer taught. In 2005, a report of four cases called attention to this rare, but tragic, complication of brain death/strokes.4 In 2009, the Anesthesia Patient Safety Foundation called for more clinical and experimental research.5 We now better understand the physiologic mechanisms, etiology, prevention, and anesthetic management of this problem.6The lower limit of autoregulation to maintain cerebral blood flow was revised upward from 50 mmHg to 70 to 80 mmHg.7 When patients are positioned upright under general anesthesia with positive pressure ventilation, blood pressure usually decreases well below the patient’s baseline or preoperative level to MAPs of 60 to 70 mmHg. If these low cuff blood pressures are not restored toward baseline levels and may even drift down further to MAPs in the 40- to 60-mmHg range, cerebral perfusion pressure will be in the 20- to 50-mmHg range.Therefore, it is critically important, when evaluating the etiology of brain death or stroke in these patients, to account for the gravitational effect on cerebral perfusion pressure in order to include severe hypotension leading to brain damage in the differential diagnosis of the ischemic stroke. Thus, it is recommended that cuff blood pressure be maintained at or near baseline to better protect cerebral perfusion.6,8,9As Drummond states,10 “We cannot take assurance from the notion that at any given time, ‘some’ of the brain is not ischemic. It would be slim consolation to the devastated patient or their families to know that blood flow continues to some portions of the nervous system while disabling damage was evolving in others.”The author declares no competing interests.

ASA/APSF Ellison C. Pierce Patient Safety Memorial Lecture: ‘Anesthesia Safety in an Asymmetrical World’

Article| July 2021 ASA/APSF Ellison C. Pierce Patient Safety Memorial Lecture: ‘Anesthesia Safety in an Asymmetrical World’ Mark A. Warner, MD Mark A. Warner, MD Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor July 2021, Vol. 85, 38. https://doi.org/10.1097/01.ASM.0000758384.12366.03 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share MailTo Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Mark A. Warner; ASA/APSF Ellison C. Pierce Patient Safety Memorial Lecture: ‘Anesthesia Safety in an Asymmetrical World’. ASA Monitor 2021; 85:38 doi: https://doi.org/10.1097/01.ASM.0000758384.12366.03 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: patient safety, safety Saturday, October 9 The 2021 ASA/APSF Ellison C. Pierce Patient Safety Memorial Lecture will be delivered by Angela Enright OC, MB, FRCPC. Dr. Enright has chosen the topic “Anesthesia Safety in an Asymmetrical World” for her lecture. This annual honorary lecture was established by the Anesthesia Patient Safety Foundation (APSF) and ASA to recognize and sustain the memory of the founding APSF President and past president of ASA (1984), Ellison C. (Jeep) Pierce, Jr., MD. It was Dr. Pierce's vision and unwavering commitment to anesthesia patient safety that led to the formation of APSF in 1985 as the first medical specialty foundation devoted solely to addressing patient safety. Today, the specialty of anesthesiology, ASA, and APSF are recognized as pioneers in advocating for patient safety as APSF strives to achieve its vision that “no one shall be harmed by anesthesia care.” APSF is the largest private funding source for anesthesia... You do not currently have access to this content.

A Collaborative Partnership between the Multicenter Handoff Collaborative and an Electronic Health Record Vendor.

Objectives The operating room is a specialized, complex environment with many factors that can impede effective communication during transitions of care between anesthesia clinicians. We postulated that an efficient, accessible, standardized tool for intraoperative handoffs built into standard workflow would improve communication and handoff safety. Most institutions now use an electronic health record (EHR) system for patient care and have independently designed intraoperative handoff tools, but these home-grown tools are not scalable to other organizations and lack vendor-supported features. The goal of this project was to create a standardized, intraoperative handoff tool supported by EHR functionality. Methods The Multicenter Handoff Collaborative, with support from the Anesthesia Patient Safety Foundation, created a working group of frontline anesthesia experts to collaborate with a development team from the EHR vendor (Epic Systems) to design a standardized intraoperative handoff tool. Over 2 years, the working group identified the critical elements for the tool and software usability, and the EHR team designed a standardized intraoperative handoff tool that is accessible to any institution using this EHR. Results The first iteration of the intraoperative handoff tool was released in August 2019, with a second version in February 2020. The tool is standardized but customizable by individual institutions. Conclusion We demonstrate that work on complex health care processes critical to patient safety, such as handoffs, can be performed on a national scale through cross-industry collaboration. Frontline experts can partner with health care industry vendors to design, build, and release a product on an accelerated timeline.

Editorial introductions.

Editorial introductions.

The Anesthesia Patient Safety Foundation Stoelting Conference 2019: Perioperative Deterioration-Early Recognition, Rapid Intervention, and the End of Failure-to-Rescue.

The Anesthesia Patient Safety Foundation Stoelting Conference 2019: Perioperative Deterioration-Early Recognition, Rapid Intervention, and the End of Failure-to-Rescue.

USNS COMFORT (T-AH 20) Surgical Services Response to the COVID-19 Pandemic in New York City.

USNS COMFORT (T-AH 20) Surgical Services Response to the COVID-19 Pandemic in New York City.