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The Science of Delivering Safe and Reliable Anesthesia Care

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Surgical Patient Care

Abstract

The healthcare system has only recently begun to approach patient safety in a more systematic way. The practice of anesthesia has moved from one of low to medium reliability and safer delivery of care, leading healthcare. However, many challenges remain. Effective anesthesia and sedation, while also controlling pain and anxiety, improves patient satisfaction and safety. The traditional approach within medicine has been to stress the responsibility of the individual and to encourage the belief that the way to eliminate adverse events is to get individual clinicians to perfect their practices. This simplistic approach not only fails to address the important and complex systematic flaws that contribute to the genesis of adverse events, but also perpetuates a myth of infallibility that is a disservice to both clinicians and their patients. The focus on the actions of individuals, without addressing the underlying system, as the sole cause of adverse events inevitably results in continued system failures and subsequent injuries and deaths of patients undergoing surgery. Strategies to make anesthesia care safer include adoption of reliability engineering principles, technological advancements in monitoring, setting up robust “near miss” reporting systems, applying critical event analysis tools such as trigger tools and failure mode and effects analysis (FEMA), wide adoption of simulation and team training, deploying standardized medications, implementing robust handoff protocols, and adherence to the American Society of Anesthesiologists and World Federation of Societies of Anaesthesiologists practice parameters. Attributing errors to system failures does not absolve physicians and nurses of their duty to care. In fact, acknowledging system failures adds to that duty the responsibility to admit errors, investigate them, and participate in redesign of the system. The development of a safety culture and climate amongst all members of the perioperative team can lead to delivery of reliable and patient-centered perioperative care.

“Patient safety is truly the framework of modern anesthetic practice, and we must redouble efforts to keep it strong and growing.”

—Ellison C. (Jeep) Pierce, Jr., M.D.; Founding Leader of the APSF

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Abbreviations

AAR:

After action review

ABA:

American Board of Anesthesiology

AfPP:

Association for Perioperative Practice

AIMS:

Anesthesia information management systems

AIRS:

Anesthesia incident reporting system

AORN:

Association of Perioperative Registered Nurses

APSF:

Anesthesia Patient Safety Foundation

AQI:

Anesthesia Quality Institute

ASA:

American Society of Anesthesiologists

CCAP:

Closed claims analysis project

CMS:

Centers for Medicare and Medicaid Services

CRM:

Crisis Resource Management

DISS:

Diameter index safety system

EHR:

Electronic health records

FDA:

Food and Drug Administration

FMEA:

Failure mode and effects analysis

ICU:

Intensive care unit

MOCA:

Maintenance of certification in anesthesiology

MPOG:

Multicenter Perioperative Outcomes Group

NACOR:

National Anesthesia Clinical Outcomes Registry

NQF:

National Quality Forum

OSCE:

Objective structured clinical examination

PPAI:

Practice performance assessment and improvement

PQRS:

Physician quality reporting system

PSH:

Perioperative surgical home

QCDR:

Qualified Clinical Data Registry

RCA:

Root cause analysis

SCIP:

Surgical Care Improvement Project

SRE:

Serious reportable events

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Authors and Affiliations

  1. Department of Anesthesiology, Tufts Medical Center, 800 Washington Street, 298, Boston, MA, 02111, USA

    Maurice F. Joyce MD, EdM, Holly E. Careskey MD, MPH & Ruben J. Azocar MD, MHCM, FCCM

  2. Children’s Cardiomyopathy Foundation and Kyle John Rymiszewski Research Scholar, Children’s Hospital of Michigan, Wayne State University School of Medicine, 5057 Woodward Avenue, Suite 13001, Detroit, MI, 48202, USA

    Paul Barach BSc, MD, MPH, Maj (ret.) (Clinical Professor)

Authors
  1. Maurice F. Joyce MD, EdM
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  2. Holly E. Careskey MD, MPH
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  3. Paul Barach BSc, MD, MPH, Maj (ret.)
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  4. Ruben J. Azocar MD, MHCM, FCCM
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Corresponding author

Correspondence to Ruben J. Azocar MD, MHCM, FCCM .

Editor information

Editors and Affiliations

  1. Department of Surgery Ascension Saint Agnes Hospital Armstrong Institute for Patient Safety & Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Juan A. Sanchez

  2. Children’s Cardiomyopathy Foundation and Kyle John Rymiszewski Research Scholar, Children’s Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA

    Paul Barach

  3. Department of Surgery Center for Healthcare Studies Institute for Public Health and Medicine Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Julie K. Johnson

  4. Division of Cardiovascular Surgery Johns Hopkins All Children’s Heart Institute Johns Hopkins All Children’s Hospital, Johns Hopkins University, Saint Petersburg, FL, USA

    Jeffrey P. Jacobs

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Joyce, M.F., Careskey, H.E., Barach, P., Azocar, R.J. (2017). The Science of Delivering Safe and Reliable Anesthesia Care. In: Sanchez, J., Barach, P., Johnson, J., Jacobs, J. (eds) Surgical Patient Care. Springer, Cham. https://doi.org/10.1007/978-3-319-44010-1_21

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  • DOI: https://doi.org/10.1007/978-3-319-44010-1_21

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