Anesthesia Patient Safety: Still a Long Way to Go

摘要

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.