SAFETY AND CRISES IN AVIATION AND IN ANESTHESIOLOGY PRACTICE
January 20, 2009
Like everyone who followed the story of the Miracle on the Hudson, the emergency water landing of US Airways Flight 1549 on January 15, we were grateful for the survival of all 155 persons aboard. We were awestruck by the skills of the pilot, Captain Chesley B. Sullenberger III and profoundly impressed by the coordination and efficiency of the crew and of the rescue efforts.
Anesthesiology adopted some of the theory and techniques of the aviation industry in becoming one of the great success stories in increasing patient safety. The use of simulators, protocols and checklists and of systems analysis is routine in both aviation and anesthesiology practice. As explained by Robert K. Stoelting, M.D., president of the Anesthesia Patient Safety Foundation in an article in the November 2006 issue of the ASA Newsletter (arguing that randomized controlled clinical trials are not the only reliable source of knowledge in improving safety),
Aviation relied on widespread implementation of hundreds of small changes in procedures, equipment, training and organization that aggregated to establish a strong safety culture and effective practices. These changes made sense, were usually based on sound principles, technical theory or experience and addressed real-life problems, but few (if any) were subjected to controlled experiments.
In health care, the progress in anesthesia safety is a comparable example. All agree that the current practice of anesthesiology provides an outstanding example of how a high level of patient safety can be achieved in health care. …. [A]nesthesia safety was achieved by applying a whole host of changes that made sense (seemed like the right thing to do) and were based on an understanding of human factor principles.
An example of applying a host of small changes based on an understanding of human factor principles and human error theory is the 2008 launch of the World Health Organizations’ Safe Surgery Saves Lives Campaign, in which APSF leaders participated and which the APSF endorsed. The campaign’s first product is the Surgical Safety Checklist, First Edition. The checklist emphasizes the overarching need for teamwork, particularly in the time-out designed to prevent wrong-site surgery. It works -- in an international study involving 3955 consecutively enrolled patients undergoing surgery between October 2008 and September 2008, researchers have just reported that “the rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).” Special Article published at www.nejm.org on January 14, 2009, Haynes AB, Weiser TG et al., A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.
The “Miracle on the Hudson” demonstrated the extraordinary value of teamwork, team and individual training and of course of Captain Sullenberger’s lengthy experience both in flying (nearly 20,000 flying hours) and as a Local Air Safety Chairman and Accident Investigator for the Air Line Pilots Association. The amazingly steady landing of the aircraft would not by itself have ensured the survival of those aboard Flight 1549, however. Also critical were the skill of the entire crew in evacuating the cabin and the immediate response of the ferry boat operators, the Coast Guard, the New York Fire Department and others.
Does the analogy to aviation safety hold, we wonder, when the anesthesia service is performed by health care professionals from other specialties? In a freestanding endoscopy center, for example, does the gastroenterologist have significant experience in managing an anesthesia catastrophe? Let us not forget that propofol, the preferred agent, does produce general anesthesia. Does the gastroenterologist’s nurse have practice in identifying and helping to revive patients who stop breathing? Is there an immediately-available rescue system, or is the emergency backup a 911 call?
Catastrophic events during anesthesia for endoscopy are exceedingly rare, fortunately. The number of procedures being performed in private offices, which in most states do not need to be accredited and for which there are generally no practitioner credentialing requirements, however, continues to grow, according to the ASA (April 23, 2008 Letter to the Food and Drug Administration urging that the propofol “black box warning” label be mandated for fospropofol as well – in December, ASA reported that fospropofol would in fact require labeling stating that the drug “should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the diagnostic or therapeutic procedure. Patients should be continuously monitored during sedation and through the recovery process for early signs of hypotension, apnea, airway obstruction, and/or oxygen desaturation. Facilities for providing cardiopulmonary resuscitation must be immediately available.”).
Training “in the administration of general anesthesia” entails immersion in a professional culture that has attained the highest levels of patient safety. The management of the last moments of Flight 1549 and the survival of 155 individuals on the aircraft depended on a similar culture of operator training, safety checklists and the systematic investigation of accidents and analysis of their causes. That culture is the reason why professionals trained in the administration of general anesthesia should always and exclusively be entrusted with providing the service.
ABC is proud to be associated with the specialty whose outstanding commitment to safety improvement was recognized by the Institute of Medicine in 1999 and by the Wall Street Journal in 2005.