Safety, Quality, & Performance Improvement

Key Concepts

In the 1980s, anesthesiologists were recognized for being the first medical specialty to adopt mandatory safety-related clinical practice guidelines. Adoption of these guidelines, describing standards for basic monitoring during general anesthesia, was associated with a reduction in the number of patients suffering brain damage or death secondary to ventilation mishaps during general anesthesia.
In 1999 the Institute of Medicine of the (U.S.) National Academy of Sciences summarized available safety information in its report, To Err is Human: Building a Safer Healthcare System, which highlighted many opportunities for improved quality and safety.
It has long been recognized that quality and safety are closely related to consistency and reduction in practice variation.
There is a natural tendency to assume that errors can be prevented by better education or better management of individual workers (ie, to look at errors as individual failures made by individual workers rather than as failures of a system or a process). To reduce errors one changes the system or process to reduce unwanted variation so that random errors are less likely.

Patient Safety Issues

As a profession, anesthesiology has spearheaded efforts to improve patient safety. Some of the first studies to evaluate safety of care focused on provision and sequelae of anesthesia. When spinal anesthesia was virtually abandoned in the United Kingdom (after two patients developed paraplegia following administration of spinal anesthetics), Drs Robert Dripps and Leroy Vandam helped prevent this technique from being abandoned in North America by carefully reporting outcomes of 10,098 patients who received spinal anesthesia. They determined that only one patient (who proved to have a previously undiagnosed spinal meningioma) developed severe, long-term neurological sequelae.

After halothane was introduced into clinical practice in 1954, concerns arose about whether it might be associated with an increased risk of hepatic injury. The National Halothane Study, perhaps the first clinical outcomes study to be performed (long before the term outcomes research gained widespread use), demonstrated the remarkable safety of the then relatively new agent compared with the alternatives. It failed, however, to settle the question of whether “halothane hepatitis” actually existed.

In the 1980s, anesthesiologists were recognized for being the first medical specialists to adopt mandatory safety-related clinical practice guidelines. Adoption of these guidelines was not without controversy, given that for the first time the American Society of Anesthesiologists (ASA) was “dictating” how physicians could practice. The effort resulted in standards for basic monitoring during general anesthesia that included detection of carbon dioxide in exhaled gas. Adoption of these standards was associated with a reduction in the number of patients suffering brain damage or death secondary to ventilation mishaps during general anesthesia. A fortunate associated result was that the cost of medical liability insurance coverage also declined.

In 1984, Ellison Pierce, president of the ASA, created its Patient Safety and Risk Management Committee. The Anesthesia Patient Safety Foundation (APSF), which celebrated its 25th anniversary in 2011, was also Dr Pierce’s creation. The APSF continues to spearhead efforts to make anesthesia and perioperative care safer for patients and practitioners. Similarly, through its guidelines, statements, advisories, and practice parameters, the ASA continues to promote safety and provide guidance to clinicians. As Dr Pierce noted, “Patient safety is not a fad. It is not a preoccupation of the past. It is not an objective that has been fulfilled or a reflection of a problem that has been solved. Patient safety is an ongoing necessity. It must be sustained by research, training, and daily application in the workplace.”

Meanwhile, other specialties of medicine began to place greater emphasis on quality and safety. In 1999 the Institute of Medicine (IOM) of the (U.S.) National Academy of Sciences summarized available safety information in a report entitled To Err is Human: Building a Safer Healthcare System. That document highlighted many opportunities for improved quality and safety in the American health care system. A subsequent IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century,