Baby Memorial Hospital, Kozhikode, Kerala,
India. PIN: 673004
Keywords: safety,
anaesthesia
‟Safety is not an intellectual exercise to keep us in
work. It is a matter of life and death. It is the sum of
our contributions to safety management that determines
whether the people we work with live or dieˮ- Sir
Brian Appleton.
Anaesthesiologists are proud of their reputation for safety!
From the first reported anaesthesia mishap onwards (Hannah
Greener about 170 years ago) anaesthesiologists were always
concerned about the safety of their patients. Anaesthesia -
related mortality is always an important public health concern
and the fact is that it's preventable most of the time. Over
the years, things have evolved drastically in favour of
patient's safety, thanks to the untiring work of
anaesthesiology fraternity. Awareness by the lay public and
medical administrators also played a major role.
Now, it may be surprising know the fact that it is the only
specialty in health care to have attained the six sigma defect
rate!! [1] (A six sigma process incidentally is defined as one
in which 99.99966% of the end product are statistically free
of defect). There are innumerable studies from the 19th
century onwards which clearly showed a reduction in
anaesthesia related mortality. In fact, from 1980 onwards,
there is a drastic reduction (10 fold decrease) in anaesthesia
related mortality [2]. Statistics even show a steep reduction
in morbidity associated with anaesthesia over the years [1].
Based on the results of peri-operative mortality, the
specialty has been hailed as the model of improvements and
patient safety in medical science [1].
So how did the speciality attain this invincible level? Safety
is the result of different components of the anaesthesia
system, i.e., professionals, equipments and facilities.
Compromising any of the above components can pose the risk of
perioperative mishaps! There have been tireless efforts by the
past anaesthesia fraternity to improve the facilities (getting
proper monitors and other equipments like anaesthesia machine
with inbuilt safety features). The essence of all monitors is
to detect impairment in tissue oxygenation! Academic refresher
courses and workshops will help the professionals to update
their current understanding of the subject and sharpen their
skills. There are encouraging feedbacks regarding simulation
based workshops in terms of communication and decision making
skills. Increasing the knowledge base will help in decision
making and avoid errors in judgment!
Present day anaesthesia practice involves lot of checklists
and protocols. These were evolved over a time looking into and
analyzing the reported errors and adopting what is best for
the evidence based medicine. There are international standards
for conducting the safe practice of Anaesthesia, which was
adopted by the World Federation of Society of
Anaesthesiologists on 13th June 1992 [3]. This was later on
subjected to further revisions periodically. But the most
important component is the presence of a qualified anaesthesia
provider! So the major credit for making anaesthesia safe
should go undoubtedly to anaesthesiologist itself. Only a
trained professional can interpret and correct early warning
signs from the monitor!
The evolution process towards safety has similarity with that
of aviation industry [4]. It is true that safety precautions
are adapted after analyzing the so-called mistakes or
deficiencies in the system. Human errors in the system are
always identifiable, predictable, repetitive and so
preventable! So how do we know something went wrong unless the
person involved in the error reports the same in the medical
forum? Anaesthesiologists are the first among medical
professionals to evolve such system called incident reporting.
Reported incidents may be anonymous and if known also must be
handled in a non-punitive manner. Errors are later on
subjected to technical dissection and analysis to find out
corrective steps. This will definitely lead to an enhanced
learning, correction and prevent it from recurring.
The pioneering work in this regard was done by Cooper [4] in
1978. What he did was interviewing staff and residents in
anaesthesia to analyze (root cause analysis) preventable
incidents [5]. In addition to initiating the corrective
strategies, due credit must also be given to Cooper for
recognizing near misses (more common than adverse events) and
pointing out the limitations of retrospective data. There were
subsequent studies on critical incidents from Cooper and
colleagues with the objective of learning from mistakes rather
than allocating blame [6]! Years later Runciman developed
Australian Incident Monitoring Study [4] (Incident reporting).
So all these laid the foundation for the anonymous reporting
of critical incidents and definitely improved the safety
standards in anaesthesia. It has to be put on records that the
anaesthesiologists efforts in this direction started even
before the WHO Safe Surgery Saves Lives Project [7]!
In continuation of the objective to achieve higher safety
standards, World Federation of Societies of Anaesthesiologists
(WFSA) launched a campaign called SAFE-T (Safe Anaesthesia for
Everyone Today). The main aim of the SAFE-T is to create
awareness and improve knowledge about the importance of safe
Anaesthesia and safe surgery. Improving safety levels
invariably uplift the quality of care to a more efficient and
effective standard. Quality of care complements the practice
of evidence based medicine [8]. The best technique for patient
safety and quality of care is simply reducing the gap between
known best practices and the actual delivery of care. A good
safety track record and better quality of care invariably
translate to less number of medico-legal litigation. As
professionals, we are so obsessed with correcting correctable
causes for error during our practice. If you scan through any
recent journals, there will be articles relating this topic.
One interesting article is recent guidelines for safe
medication practice in European Journal of Anaesthesiology
[9]. A positive impact of reduced mortality is that insurance
premiums for anaesthetists have remained stable or even
decreased in European and North American countries [10]. Even
with best medical practice, sometimes unreliable delivery can
happen (adverse events) [11]. But that is part and parcel of
the game!
The funny part of Anaesthesiologists' compulsion to avoid
mistakes and strive for perfection is that most of us suffer
from a bit of obsessive compulsive element!
References
1. Morbidity in anaesthesia today and tomorrow. Guy Haller.
Best Practice and research Clinical Anaesthesia 2011;
25:123-32.
2. Arbous MS, Meursing AE, Vankleef JW et al. Impact of
anaesthesia management characteristics on severe morbidity and
mortality. Anesthesiology 2005; 102:257-68.
3. Alan.F.Merry, Jeffrey Cooper. International standards for a
safe practice of Anaesthesia. Can J Anaesth 2010; 57: 1027-34.
4. AF Merry. Safety in Anaesthesia: reporting incidents and
learning from them. Anaesthesia 2008; 63:337-9.
5. Cooper JB, New bower RS, Long CD, Mc Peek B. Preventable
anaesthesia mishaps: a study of human factors. Anaesthesiology
1978; 49:399-406.
6. Cooper JB, Long CD, New bower RS, Philip JH. Critical
incidents associated with intraoperative exchange of
anaesthesia personnel. Anesthesiology 1982; 56:456-61.
7. Haynes AB, Weiser TG, Berry WR et al. A surgical safety
checklist to reduce morbidity and mortality in a global
population. New England Journal of Medicine 2009; 360:491-9.
8. Peden CJ, Rooney KD. The science of improvement as it
relates to quality and safety in the ICU. J Intens Care Soc
2009;10:260-5.
9. David Whitaker, Gutton Brattebo et al. The European Board
of Anaesthesiology recommendations for safe medication
practice. Eur J Anaesthesiol 2017;34:4-7.
10. Domino KB. Trends in Anaesthesia litigation in the
1990s.Monitored anaesthesia care claims. ASA Newsletter 1997;
61:15-7.
11. Weller JM, Merry AF. Best practice and patient safety in
anaesthesia. BJA 2013;110:671-3.