Anesthesia Patient Safety: Still a Long Way to Go

The father of the anesthesia patient safety movement, Dr Ellison C. Pierce of Boston, developed an interest in anesthesia safety in the 1960s, after the death under anesthesia of the 18-year-old daughter of a friend, following an unrecognized esophageal intubation. His interest grew when he became involved in studies of “critical incidents” undertaken by Jeffrey Cooper, PhD, of the Massachusetts General Hospital. Anesthesia patient safety became a public phenomenon in the United States in 1982 when the television program 20/20 aired an episode called “The Deep Sleep: 6000 Will Die or Suffer Brain Damage.” The allegations contained therein shocked the public but also anesthesiologists and their professional societies around the world. Thus began one of the most successful drives for improvement in patient safety, with anesthesia subsequently being recognized as a leader in the field.1 How have these improvements been achieved? The answer is complex and varied, and it includes a multitude of approaches to address the problem: Wide recognition that there is a problem Study of critical incidents including near-misses Organizations devoted to studying the problem, for example, Anesthesia Patient Safety Foundation Development of standards and guidelines by national and international societies Better education and training of anesthesia providers Improved technology in anesthesia Widespread use of monitoring Safer anesthetic medications Advances in simulation Introduction of checklists Warner et al2 in their article, published in this issue of Anesthesia & Analgesia, present us with a cross-sectional snapshot of anesthesia safety around the world. They have invited anesthesiologists from 13 high-, middle-, and low-income countries to describe the issues they currently face in the provision of safe anesthesia and to outline their needs for the future. So what have we learned? It is clear that all of these countries recognize that more must be done to address issues around patient safety. The challenges vary somewhat depending on the economic status of each country. Those on the middle and lower end of the income scale continue to lack adequate and appropriate equipment to administer safe anesthesia and to adequately monitor patients.2 Regular availability of anesthetic medications is essential.2 Supply chains are often inadequate for a variety of reasons including failure to recognize this important need, deficient resources, and disorganized management.3 Two related, very disturbing messages come through in Warner et al’s2 article. Although standards, guidelines, and checklists are widely available and recognized, even mandated, there seems to be a reluctance to comply with them, even in some high-income countries.2 Indeed, Dr Ibarra (a coauthor) refers to “systemic violation of healthcare standards” as “a major healthcare issue in Colombia.” Similar observations have been made in other countries, for example, in the cited article from Wachter and Pronovost. At the same time, we read (with concern) about the increased use of the criminal law to punish medical errors, with a call for “no blame, no shame” environments. A nurse in Tennessee is currently facing criminal charges after the accidental administration of vecuronium instead of midazolam, tragically with fatal consequences for the patient.4 This case is illustrative of the complexity of many medical accidents, because it is alleged that in addition to simple error, an element of violation—in effect, recklessness—was involved, in that the nurse, in selecting the ampule, chose to override the computerized medication dispensing machine, designed to prevent errors of this type. The nurse’s defense includes statements to the effect that such overrides are commonplace in her institution and elsewhere, and they have been requested by the hospital administration to overcome delays and technical problems associated with an overhaul of the institutional electronic medical record system. On the face of it, this case is an example of normalized deviation.5 Normalized deviation is widespread and has many faces. For example, there are many parts of the world in which internationally accepted safety standards cannot be met because of the lack of resources, as well as many others in which poor aspects of system design or culture promote workarounds simply to get essential work done and to provide patients with the care they need, albeit with a reduced level of safety. The role of regulation and the law in improving patient safety is a complex matter, and has been explored in detail elsewhere.5 In essence, what is needed is a just culture in which compliance with safety standards, engagement in safety initiatives, and a commitment to mutually respectful behavior between all members of the perioperative team are expected and enforced, using proportionate sanctions when necessary. An essential element of a just culture is an understanding by all concerned stakeholders that unduly harsh punishment will not follow simple errors made while trying conscientiously to provide patients with the care they need. In particular, it is essential that the criminal law is restricted to genuinely egregious cases, in part because the processes of the criminal courts seldom focus on the issues underlying failures in safety—for example, the potential responsibility of the hospital administration in the Tennessee case—and seldom advance the cause of patient safety. At the same time, it is essential to ensure that standards are adequately introduced to practitioners, with education about their importance and adequate demonstration of how they can be utilized efficiently on a daily basis. A further example can be found with the Surgical Safety Checklist. There is ample evidence that using this tool can reduce perioperative morbidity and mortality in all countries,6 yet we read that its poor implementation in Spain was actually counterproductive to patient safety. Tools of this sort typically require users to adapt them to their own environment, as part of engaging with their effective use.7 Health care systems, including the regulation of health care, should start from the basic assumption that almost all health care workers want to provide the best and safest possible care to their patients, and they will do so if given adequate direction, encouragement, and support. It is necessary to recognize variation in resources, and fascinating to contrast a call for new and more sophisticated technology in the United States with a plea for the basic minimum in existing resources from Nigeria. The World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) Standards of Practice8 were carefully crafted to recognize that many countries would not be able to immediately access the equipment recommended. A good example is the use of capnography, which is mandated in high-income country standards.9,10 However, capnography is rarely available in low-income countries. But efforts are underway to address this issue.11 Together, Lifebox, Smile Train, and WFSA are in the process of developing a capnograph that will be suitable and accessible for use in economically challenged environments. It will be accompanied by an educational package for those to whom capnography is new: following the success of the Lifebox oximetry project, which has grown from small beginnings in 2004, as the Global Oximetry Project of the WFSA.12 The African Surgical Outcomes Study,13 among others, has shown that many perioperative deaths occur in the postoperative period due to failure to promptly recognize and to effectively treat the deteriorating patient. It is clear from Warner et al’s2 article that this problem is being recognized almost everywhere and the need to address it is urgent. Japan has introduced multidisciplinary perianesthesia care teams to focus on patient safety.2 Another issue recognized by Warner et al2 in their article is the frequency of problems when patients undergo procedures outside of the operating room environment. These authors tell us that “more than 50% of surgical, diagnostic and interventional procedures in the US are now being performed outside of typical operating rooms.”2 Anesthesia in these cases may be administered by nonanesthesiologists/anesthetists without appropriate training—or even appreciation of the challenges—and without the proper facilities or equipment to effect patient rescue when things go wrong.14 Hypoxemia, oversedation, apnea, and hypotension were commonly reported. Permanent or severe harm to the patient occurred in 5.8% of the cases.14 Airway problems continue to occur, not only during anesthesia but also throughout the hospital. A new approach to addressing this issue is being taken in several countries, namely the United Kingdom, Ireland, New Zealand, and Australia.15 This involves the development of an Airway Lead Network for each hospital. The Airway Lead, usually from anesthesia, will help establish a multidisciplinary network, ensure quality, standardization and supply of airway equipment, promote use of guidelines and lead audit and training throughout the hospital. In this way, it is hoped that further airway mishaps will be avoided. The need for effective teamwork, both within and outside the operating room, is an issue for all countries.2 The days of silos should be over, but unfortunately, they are not. New Zealand is a leader in improving team communication, but other countries, for example, Lebanon, indicate their goals to do so.2 Simulation is used in many countries to promote teamwork and communication. High-tech simulation is not always required. There are several widely used low-tech programs such as Safer Anaesthesia from Education Operating Room (SAFE OR)16 and Vital Anaesthesia Simulation Training (VAST)17 that work on team nontechnical skills. These are readily accessible to everyone, everywhere. The acquisition and use of data is one of the last frontiers to be conquered. Even in high-income countries, this can be problematic as systems are expensive to acquire and funding in health care is always constrained. The problem is even more acute in regions with limited resources and many competing priorities. Professor Bruce Biccard and his team from Cape Town have demonstrated in their African surgical outcome studies what can be done when appropriate efforts are made.13 The Indian Society of Anaesthesiologists has established a national registry to collect standardized perioperative quality and safety data.2 In addition, some new ideas are coming forward as to how data might be gathered from providers in hospitals that do not have access to digital data. Innovative work is being done in Rwanda to harness the ubiquitous cellular phone network.18 The National Institutes of Health, through their Harnessing Data Science for Health Discovery and Innovation in Africa, have funded projects focused on data gathering.19 The wider social structure is often underrated in considerations of patient safety. We have already referred to the regulation of health care, but national and global challenges such as we have seen through the recent coronavirus pandemic massively impact health outcomes, directly and indirectly. Important surgery has often had to be postponed, while at the same time, the risk of surgery and anesthesia has increased. This has occurred both through the direct influence of the virus on outcomes and through the pressure on health care professionals, especially anesthesiologists and nurses, who have had to work exceedingly long hours and have been denied weekends and holidays to catch up. They have at times felt treated as if they were robots with no care at all for their well-being. The long-term impact of the loss of many practitioners from the system has yet to be understood. Adding to this huge challenge to the world, we have now seen, yet again, the massive and horrific effects of war. In Ukraine, thousands of people, both military and civilian, have been killed directly in the fighting. In addition, the impact of destroyed infrastructure, including homes and hospitals, has yet to be fully understood, but as always with war, this will probably exceed the toll of direct casualties.20 The potential specter of so called tactical nuclear weapons is beyond terrible. The article from Warner et al2 evokes some satisfaction through the participants’ accounts of engagement and progress in the cause of better and safer patient care by anesthesiologists in their various and varied countries. It also provides cause for considerable concern through its stark accounts of substantial inequities in the perioperative care received by patients in different countries and indeed within countries. We must of course all continue to advance the standards in our own countries, but it is also clear that as a global anesthetic community, we need to increase our collective efforts to address the pressing challenges still faced by anesthesia providers attempting to care for sick and injured patients in many parts of the world. DISCLOSURES Name: Angela Enright, MB, FRCPC. Contribution: This author helped write the article. Conflicts of Interest: A. Enright is a former President of the WFSA; former member of Board of Directors of Lifebox. Name: Alan F. Merry, MB, FANZCA. Contribution: This author helped write the article. Conflicts of Interest: A. F. Merry is a member of the Board of Directors of Lifebox and declares financial interests in Safer Sleep LLC. This manuscript was handled by: Thomas R. Vetter, MD, MPH.

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