IMPROVING ANESTHESIA SAFETY
Over the past several decades, there have been major initiatives
to improve the safety of anesthesia. In 1984, Cooper, Kitz, and Ellison hosted the
first International Symposium on Preventable Anesthesia Mortality and Morbidity in
Boston. Approximately 50 anesthesiologists from around the world attended the meeting
and, after much debate, established a series of definitions of outcome, morbidity,
and mortality ( Table 24-20
).
These meetings have been held every 2 years since the first symposium. The Anesthesia
Patient Safety Foundation was established as a result of the Boston meeting. The
society has been active in publishing widely circulated newsletters and awarding
annual grants. Similar societies have been established in countries outside the
United States, and a National Patient Safety Foundation has been created on the same
model.
Starting with the ACCS, there has been much interest in establishing
guidelines for best and safest practice. Practice policies or guidelines are summations
by clinicians of the available evidence about the benefits and risks of particular
treatment plans. Guidelines are a method of codifying recommendations regarding
the use of a given technology. Several types of recommendations fall into the general
category of a practice parameter. A standard implies
that a therapy or practice should be performed for patients with a particular condition.
Standards are approved only if an assessment of the probabilities and utilities
of the group indicate that the decision to choose the treatment or a strategy would
be virtually unanimous. If a particular therapy or strategy is considered a standard,
it is a cost-effective measure for those for whom it is being recommended. Standards
are intended to be applied rigidly. The ASA has established Standards for Intraoperative
Monitoring, which were developed from safety guidelines adopted by the Harvard University
hospital system. Guidelines are intended to be more flexible than standards, but
they should be followed in most cases. Depending on the patient, the setting, and
other factors, guidelines can and should be
TABLE 24-20 -- Proposed definitions from the 1994 International Symposium on Preventable
Anesthesia Morbidity and Mortality
|
Outcome |
|
Normal |
|
Abandoned procedure |
|
Morbidity |
|
Death |
|
Morbidity |
|
An unplanned, unwanted, undesirable consequence of
anesthesia |
|
Mortality |
|
Death that occurs before recovery from effects of
a drug or drugs given to facilitate a procedure |
|
Death that occurs during an attempt to relieve the
pain of a condition |
|
Death that results from an incident that occurs while
the drugs are effective |
|
Adapted from Pierce EC Jr: The 34th Rovenstine Lecture:
40 years behind the mask: Safety revisited. Anesthesiology 84:965, 1996. |
tailored to fit individual needs. Like standards, guidelines should be cost-effective
methods. A number of specific guidelines have been adopted by the ASA for diverse
issues such as the difficult airway,[214]
use of
the pulmonary artery catheter,[215]
and use of blood
components.[216]
The goal is to define the evidence
on which optimal practice can be based.
There is much interest in the use of anesthesia simulators to
train and test individuals and their ability to react to simulated crises.[217]
[218]
[219]
[220]
[221]
Standardized scenarios have been developed
for making comparisons among individuals.[222]
[223]
Further research is required to determine how best to use this technology in anesthesia
training and in recertification.
