CHAPTER 8

V O L U M E T H I R T Y - S I X

ANESTHESIA AND PATIENT

SAFETY: IT’S NOT ONLY
ABOUT GETTING OUT OF
THE OR ALIVE!

ELIZABETH A. MARTINEZ, M.D., M.H.S.

ASSISTANT PROFESSOR
DEPARTMENTS OF ANESTHESIOLOGY &
CRITICAL CARE MEDICINE AND SURGERY
JOHNS HOPKINS MEDICINE
BALTIMORE, MARYLAND

EDITOR: MEG A. ROSENBLATT, M.D.

ASSOCIATE EDITORS: JOHN F. BUTTERWORTH IV, M.D.
JEFFREY B. GROSS, M.D.

The American Society of Anesthesiologists, Inc.

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 Anesthesia and Patient Safety: It’s Not Only
About Getting Out of the OR Alive!
Elizabeth A. Martinez, M.D., M.H.S.
Assistant Professor
Departments of Anesthesiology & Critical Care Medicine and Surgery
Johns Hopkins Medicine
Baltimore, Maryland

The Institute of Medicine (IOM) Report, “To Err Is Human: Building a Safer Health
System,” published in November 1999, established the problem of medical errors as a
national crisis. It outlined that the problem of medical errors is large and it estimated
that medical errors occur in approximately 7% of all patients and account for 44,000
to 98,000 deaths annually in the United States.1 In other words, they reported that
more people die in a given year from medical errors than from motor vehicle acci-
dents, breast cancer, or AIDS. In the world of perioperative medicine, this translates
into approximately 800,000 individuals who sustain a postoperative surgical site infec-
tion annually. The total costs of such errors, which include lost wages in addition to
the cost for care of the complication itself, may exceed $50 billion annually. This IOM
report also highlighted the need for systematic improvements in the safe delivery of
health care, accountability for medical errors, and has heightened the awareness of
such a need in the eyes of the medical caregivers, the public, and governmental agen-
cies.1 Despite the national focus on patient safety and care improvement this report
initiated, there is little evidence that we have made much progress along the fronts of
improving patient safety and decreasing medical errors.2 Despite far-reaching efforts,
we have been unable to provide evidence that progress has been made along these
fronts, in part as a result of a limited understanding of the science of patient safety and
the difficulty in measuring and documenting improvements in patient safety.

The Science of Safety

The science of patient safety borrows much of its foundation from disciplines such
as aviation and nuclear power plant safety. Basic tenets of patient safety are that bro-
ken systems allow errors to occur and that humans are and will always be fallible.
Errors are seen as consequences rather than causes of the broken system, having ori-
gins not in the incompetence of an individual, but rather in system factors.3 Therefore,
to decrease the risk of errors, the system must be addressed and fixed. Within this par-
adigm, the workers, or those who may be involved in the eventual errors, are not to
be the focus of blame. Furthermore, when errors occur, if the focus is on the individ-
uals, change cannot be enacted successfully; instead, the system within which the
work is done needs to be addressed and systemic contributors to the event need to be
identified and corrected to prevent the error from being repeated. This basic princi-
ple that safety is the property of each system is fundamental to improving patient
safety. An example of anesthesiology leadership in identifying system factors to elim-
inate an unsafe practice was the introduction of the pin index safety system, imple-
mented to prevent incorrect E-cylinder attachments, which had resulted in delivery of

Copyright ©2008 American Society of Anesthesiologists, Inc. 87

88 MARTINEZ

TABLE 1. The Science of Safety and Correcting System Failures

1. Identify failures
A. Active
B. Latent
2. Identify system contributors to failures
A. Frontline
B. Management
3. Implement interventions
A. Technical work
1) Standardize tasks
2) Independent checks
3) Learn from mistakes
B. Improve teamwork and communication

hypoxic gas mixtures to patients. Cylinder manufacturers adopted a unique attachment

system, thus correcting the system and not relying on individual providers to prevent
this from occurring.
For the science of safety, the term “system” refers to a set of interdependent ele-
ments that interact to achieve a shared aim. The two key elements that interact
within the system are the frontline personnel and the management of the work, who
will design, control, and redesign the work itself. For example, in anesthesiology,
this may include the frontline providers of anesthesia, the technologists who sup-
port the functioning of our monitors and technical work such as availability of equip-
ment for line placement, the operating room staff, the directors of our practice
(chairperson, business leadership, and so on), and the hospital. When evaluating and
addressing a broken system (Table 1), the first step is to identify the failures. Failures
in a system can be either active or latent.3 Active failures are associated with activi-
ties or actions done by the frontline personnel and are associated with an immedi-
ate adverse effect. Latent failures are those decisions or actions that become evident
as errors when they combine with local factors to produce injury and can arise from
managerial and organizational decisions that shape the working conditions. The latent
failures, or system vulnerabilities, are frequently a result of financial and time pres-
sures in the workplace.
The systems within which we work in medicine are complex. To improve the sys-
tems, we must implement interventions to improve both the teamwork and the tech-
nical work. Communication is the key component of teamwork. According to the Joint
Commission on Accreditation of Healthcare Organizations, communication errors are
the most common cause of sentinel events, and specifically of wrong-site surgeries, in
the United States.4
The operating room suite has unique characteristics that must be considered when
approaching improvements in teamwork and communication. Teamwork for the anes-
thesiologist must frequently extend across geographic locations and departments (for
example, the preoperative and postoperative locations, intensive care units, and mul-
tiple surgical teams and care providers).5 Recent studies have identified that the com-
munication and perceptions of teamwork in the operating room vary significantly by
provider.6 As anesthesiologists continue to strive to improve patient safety, a focus on
teamwork (communication and collaboration) needs to be included. Implementation
of an extended time-out (briefing), which includes the introduction by name of all
providers in that operating room before initiation of a surgical procedure, is an exam-
ple of how the perioperative team may make efforts to improve teamwork.
 ANESTHESIA AND PATIENT SAFETY 89

Successful efforts in system improvements that have focused on the technical work
have implemented steps to standardize tasks, create independent checks, and, impor-
tantly, to learn from mistakes when they occur. A checklist reviewed during the brief-
ing is an example of standardizing the communication among providers and can be
used as an independent check of important perioperative issues such as confirming
the correct patient, the correct procedure, and the correct surgical side; confirmation
of appropriate antibiotic administration; and planned postoperative destination.*7

Quality Improvement
The IOM’s definition of healthcare quality in the United States is “the degree to
which health services for individuals and populations increase the likelihood of desired
health outcomes and are consistent with current professional knowledge.”8 Avedis
Donabedian, a pioneer in quality improvement, proposed that we measure the quality
of health care by observing its structure, processes, and outcomes.9,10 For example,
there is evidence to support that the nurse-to-patient ratio in the intensive care unit
impacts outcomes.11 The nurse-to-patient ratio is a structural component of care. The
hospital supports the hiring of nurses to meet a set standard. A process of care may be
implementation of a tight glycemic control protocol in cardiac surgical patients
because it has been shown to improve outcomes.12 The structure of the care delivery
system is important to the way that processes can be implemented and outcomes
improved. For example, the nurse-to-patient ratio may be the key to the implementa-
tion of a safe and effective insulin protocol because it can be a high resource requir-
ing intervention and if this were implemented in an intensive care unit with a nurse-
to-patient ratio that is less favorable, more incidents of either hyperglycemia or
hypoglycemia may occur.
A key aspect of quality improvement is feedback to team members. What this means
is that when embarking on quality improvement efforts, a measurement system in
which changes can be tested and evaluated and feedback is given is paramount. How-
ever, healthcare workers are often limited in their ability to obtain feedback regarding
performance in their daily work because of lack of information systems and also lack
of agreement on how to measure the quality of care.10,13 This has long been known to
be a hindrance to quality improvement. Health care has few scientifically sound or fea-
sible measures or tools to accomplish this task, and this has contributed to the recent
reports that we have made little to no progress in improving patient safety.2 To docu-
ment improvement, we need to be able to measure and remeasure how we are doing
on a specific intervention or whether outcomes are improved after such an interven-
tion. We may measure the structure, the process, or the outcomes of care. There are
pros and cons to each of these.
Importantly, not all areas of interest in health care are conducive to rate-based
measures because we may not always know what the numerator and denominator
are. For example, with medication errors, we may never truly know what the rate
is. Over the last many years, there have been efforts to encourage providers to report
errors and improvements in our error-reporting systems. If a hospital implements
such measures, they may report an increase in the number of medication errors, but
we do not know for certain whether this represents an increase in the incidence or
just the reporting of such errors. Medication errors will never be a true rate because

*National patient safety goals. Available at: www.jointcommission.org. Accessed October 1, 2007.
90 MARTINEZ

we do not know if we have accurately identified or captured all opportunities or if

all have been reported. To measure improvement along the fronts of medication
safety, a hospital may choose to measure what safeguards have been implemented
and that they have implemented education sessions for the providers (the structure).
In the science of safety, we need to continue to focus on validating such surrogate
measures of safety so we can document and communicate our progress in a trans-
parent and reproducible fashion. When possible, nonrate-based measures of safety
should be translated into rate-based, validated surrogates to improve our ability to under-
stand our progress.
Improving communication and teamwork is one of the national patient safety
goals.* Evaluating teamwork and the local culture of safety is complex and not a rate-
based measure. The Safety Attitudes Questionnaire is a validated tool that is used to
assess safety climate and teamwork within a patient care area.14 The questionnaire has
been validated in the operating room setting in the measurement of the local safety
and teamwork climate.15 Because this survey measures group-level perceptions, the
most appropriate term to use is “climate” as opposed to “culture” because this tool
cannot measure behavior, values, or competencies.14 Importantly, teamwork climate
is a recognized marker of performance4,16; this tool can be used to track progress in
operating room teamwork and offers a method to track and document improvements
in patient safety.
There are multiple methods reported in the literature that have varying success for
improving care.17 These include use of evidence-based medicine (clinical practice guide-
lines and decision aids), professional education, accreditation and public reporting, patient-
centered care, and total quality improvement and continuous quality improvement.

Improving Quality and Safety: A Practical Model

One method that has been used successfully incorporates evidence-based medicine
and quality improvement. The premise of evidence-based medicine is that we can com-
bine the best available evidence/data along with patient values and provider prefer-
ences to determine a care plan for a given patient.18 In contrast, quality improvement
and patient safety look at ways to translate these factors into broader use or, in other
words, use within the system of care to improve the likelihood that all patients receive
the care they should (i.e., translating evidence into practice). The model incorporates
the implementation of evidence-based practices with data-driven feedback and per-
formance improvement.
The model that we have successfully developed in our intensive care units has been
applied broadly in more than 100 intensive care units19 and within our operating
rooms to improve care delivery, namely to improve our success with implementation
of the Surgical Care Improvement Project elements.20 The steps of the collaborative
model are19,20:

1. To identify an important clinical area for improvement, an area that has an

impact on the lives of patients, where there are data to support an intervention
and where there is a quality gap (a gap between what we should do and what
we are doing);
2. To identify interventions that have evidence to support their impact on improv-
ing outcomes. It is recommended to use the tenets of evidence-based medicine
to define the outcomes and interventions;
 ANESTHESIA AND PATIENT SAFETY 91

3. To measure whether we are doing what we should. Here we measure the

processes of care delivery as a marker for performance. There are many chal-
lenges in defining the measures and actually measuring them;
4. To ensure that patients receive the evidence-based processes or practices
through changing the system; and
5. To evaluate whether patient outcomes are improved.

The collaborative approach outlined here is being successfully implemented in the

perioperative setting to improve the delivery of evidence-based practices to surgical
patients. Following these steps, anesthesiologists have an opportunity to lead improve-
ments in care that have been outlined by the Joint Commission on Accreditation of
Healthcare Organizations and the Centers for Medicare and Medicaid Services in the
Surgical Care Improvement Project (SCIP).†

Step 1: Identification of an important clinical area: Surgical site infection rates remain
high with an estimated 800,000 occurring annually. Furthermore, Bratzler et al.
have shown that there was a gap between recommended and actual care deliv-
ered in a practice that had been previously shown to decrease a patient’s risk of
a surgical site infection, namely appropriate timing of prophylactic antibiotics.
They reported that this practice occurred only 56% of the time in a sample of more
than 30,000 patients nationally in the United States.21
Step 2: Review the interventions that have been shown to decrease surgical site infec-
tions. Appropriate antibiotic administration (timing, selection, and discontinua-
tion), maintenance of perioperative normothermia, appropriate hair removal, and
glycemic control in cardiac surgery.†
Step 3: Implement a measurement system to evaluate success with one or all of
the measures, depending on local resources. Evaluate this at baseline and report
the baseline compliance to local providers of how well they are performing as the
anesthesiology group or as individual providers.
Step 4: Evaluate the local system in which care is delivered and introduce interventions
to improve compliance with measures. For example, make certain that the appro-
priate antibiotics are available to the anesthesiologist who will be administering the
antibiotic or introduce checklists to confirm that antibiotics have been adminis-
tered at the appropriate time (i.e., link to the extended time-out or briefing).
Step 5: Measure whether the interventions have had an impact. Define how data
will be fed back to providers and what format will be used. An example of how
data may be presented is shown in Figures 1 and 2 using the example of the Sur-
gical Care Improvement Project measures in decreasing surgical site infections.

This model discusses the key elements of a practical approach to quality improve-
ment. One aspect to emphasize is that the key to implementation is that the local
providers are the experts on how to implement these locally. Additional steps to suc-
cessful local implementation of the collaborative model are outlined subsequently.19,21

1. Engage all caregivers by making the problem real with sharing local infection
rates or a story of a patient with a surgical site infection. Local leadership must
also support the efforts vocally to optimize engagement of all of the providers.

†Surgical Care Improvement Project. Available at: www.medqic.org. Accessed July 10, 2007.
92 MARTINEZ

10.00

SSI rate / 100 Cases 8.00

6.00

4.00

2.00

0.00
e

05

5
05

05
lin

t0
ch

ec
se

ep
un
ar

-D
Ba

-S
-J
-M

05
05
05
05

ct
ly
ril

O
n

Ju
Ap
Ja

Cohort
Your Team

FIG. 1. Sample report for quarterly surgical site infection (SSI) rates over time.

100%

80%
Percent Compliance

60%
Your Team

Other Teams in
40%
Collaborative

20%

0%
Composite Appropriate Prevention of
Abx Timing Hypothermia

Quality Measure
FIG. 2. Sample report for surgical site infection process measures comparing your team with
other teams.
 ANESTHESIA AND PATIENT SAFETY 93

In addition to leadership, local champions who are in the frontline are impor-
tant to engage other frontline providers.
2. Educate all caregivers on the evidence-based practices and the target perfor-
mance parameters, including all of the stakeholders in the process. Education of
providers can be very challenging in large and small institutions. Reaching all
providers and making them aware of the evidence-based practices, in addition
to the method of data collection and feedback and expectations or goals, is a
continuous process. It is not advisable to rely on e-mail communication, but
rather group education with opportunity for discussion of issues, concerns, bar-
riers to the planned program, and identification of local solutions.
3. Execute the quality improvement initiative and improve care delivery by chang-
ing the local culture (teamwork) and by decreasing the complexity of the sys-
tem and introducing redundancies into the system to ensure that patients
receive the care they should. Building on the science of safety, focus on systemic
changes to improve care, not the individuals, because humans are fallible. In
addition, “working” meetings of key members need to occur on a regular basis
to review the data, review the interventions, and share feedback from frontline
providers as to what is and what is not working locally to address these rapidly
and work toward modifying approaches or improving buy-in.
4. Evaluate how well the teams are doing with performance and/or outcome mea-
sures and give real-time feedback to the teams on a regular basis.

Measurement of the proposed quality improvement project can be the most difficult.
When implementing a measurement system in this example, the focus can be on either
the process measures themselves or the outcome measures (rates of infection). The Sur-
gical Care Improvement Project program focuses on both the processes of care delivery
and the outcomes. However, frequently, we do not have standardized systems, sec-
ondary to limited resources, to evaluate rates of infections. For example, locally we have
surveillance of only a few surgical services. For those services, both process measures
and outcomes are reported to those teams. For those teams who do not have infection
rates systematically evaluated by our hospital epidemiology team, they receive reports
of their compliance with the process measures only. This can make it very challenging
to engage these teams because many providers are interested in the outcomes. These
issues must be incorporated into the local implementation strategy. We have partnered
with hospital leadership to maintain this focus on the process measures to optimize
local, broad engagement.

The Future: Pay for Performance

Purchasers, insurers, and regulators all have requirements that anesthesia depart-
ments participate in quality improvement with the goal of improving care, reducing
costs, and decreasing payouts. The expectation is that data are collected and reviewed
and feedback is shared with the result being data-driven performance improvement.
This can be very challenging to departments because it can require significant resources
and it is often difficult to define measures accurately. Furthermore, as data are collected,
it is important that there is a balance between scientific rigor and feasibility to achieve
the desired goals. The pressures for quality improvement are increasing and the trend
for the future is pay for performance.
In follow up to the 1999 IOM “To Err Is Human,” the IOM submitted a report in 2001,
“Crossing the Quality Chasm,” which called for the alignment of payment policies to
94 MARTINEZ

promote quality care.22 Furthermore, public and private insurers are demanding
increased accountability secondary to rising healthcare costs and threatened budgets.
In response, “pay for performance” (p4p) has been proposed and implemented as a
means to improving quality based on successful examples in business. Pay for perfor-
mance has been defined as the use of incentives to encourage and reinforce the delivery
of evidence-based practices and healthcare system transformation that promote better
outcomes as efficiently as possible (American Healthways–Johns Hopkins 4th Annual
Disease Management Outcomes Summit, November 2004).
In 2006, the IOM put out a statement on p4p, defining what should be rewarded
and recommendations for implementation. They recommend that rewards should be
given for high-quality clinical care, care that is responsive to patients and efficient and
to those providers who communicate well with patients and coordinate care. They
also outlined recommendations for implementation23:

1. IOM supports p4p and feels that Medicare needs to move in this direction using
a phased approach to foster comprehensive and systemwide improvements;
2. Congress should derive initial funding for a p4p program largely from existing
funds. These pools should provide adequate motivation;
3. In designing p4p, health care that is of high clinical quality, patient-centered, and
efficient should be rewarded. Providers who improve performance significantly
and those who achieve high performance should initially be rewarded;
4. Eventually there should be a single p4p pool that rewards coordination of care,
fostering shared accountability among physicians and hospitals;
5. Incentives should be available for providers who report data, at least initially, to
ensure good databases and accurate data; and
6. Investments in research are needed to evaluate how this is working over time.

The Centers for Medicare and Medicaid Services has implemented this program
already; the program was preceded by evaluation of such programs in Demonstration
Projects in multiple clinical areas in which hospitals were incentivized such that the
top 10% performing centers would receive a 2% bonus, the second 10% would receive
a 1% bonus, and the bottom 30% would have a 2% decrease in year 3 of the project. Cur-
rent programs include the Medicare’s Physician Quality Reporting Initiative through
which we as anesthesia providers are eligible for a 1.5% bonus on Medicare cases for
80% compliance in the appropriate timing of prophylactic antibiotics.24 Furthermore,
the Centers for Medicare and Medicaid Services is implementing a no-payment policy
for selected cases, namely infections or complications, which were not present on
admission to the hospital. Both of these initiatives have potential for significant impact
on our practices and the hospitals within which we work.

Quality Indicators for the Perioperative Provider

In 2001, the Agency for Healthcare Research and Quality published an evidence
report, “Making Health Care Safer: A Critical Analysis of Patient Safety Practices.” This
review was designed to look at the existing evidence of patient safety practices. They
defined patient safety practices as those that reduce the risk of adverse events related
to exposure to medical care across a range of diagnoses or conditions.25 Seventy-nine
practices were identified and, using a standard evaluation and predefined consensus,
were ranked on the strength of the level of evidence supporting their impact. Of the
 ANESTHESIA AND PATIENT SAFETY 95

TABLE 2. Patient Safety Practices with the Strongest Evidence

(Agency for Healthcare Research and Quality Evidence Review)

1. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk

2. Use of perioperative beta-blockers in appropriate patients to prevent perioperative
morbidity and mortality
3. Use of maximum sterile barriers while placing central intravenous catheters to prevent
infections
4. Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative
infections
5. Asking that patients recall and restate what they have been told during the informed
consent process
6. Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia
7. Use of pressure-relieving bedding materials to prevent pressure ulcers
8. Use of real-time ultrasound guidance during central line insertion
9. Patient self-managed warfarin
10. Appropriate provision of nutrition with a particular emphasis on early enteral nutrition in
crucially ill and surgical patients
11. Use of antibiotic-impregnated central venous catheters to prevent catheter-related
infections

Adapted from Shojania KG, Duncan BW, McDonald KM, et al., eds: Making Healthcare Safer: A Critical
Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 (prepared by the Uni-
versity of California at San Francisco–Stanford evidence-based Practice Center under Contract No. 290-97-
0013), AHRQ Publication No. 01-E058. Rockville, MD, Agency for Healthcare Research and Quality,
July 2001 and www.ahrq.gov/clinic/ptsafety. Accessed August 1, 2007.

11 practices with the strongest evidence supporting their implementation, seven are
germane to the perioperative provider (Table 2). Although this report has limitations
in that it focused on individual practices and not the system changes that need to be
the focus of improving patient safety, it still presents us with areas that we can explore
to improve care.26
The American Society of Anesthesiologists have proposed measures specific for the
practice of anesthesiology (Table 3). The most recent measures (Table 3, numbers 7 to
11) have recently been posted on the American Society of Anesthesiologists web site,
requesting public comment on these additional proposed measures: 1) reduction of

TABLE 3. Potential Quality Measures: American Society of Anesthesiologists

1. Prevention of ventilator-associated pneumonia with head elevation

2. Stress ulcer disease prophylaxis in ventilated patients
3. Prevention of catheter-related bloodstream infections with the use of a catheter insertion
protocol
4. Perioperative temperature management for surgical procedures under general anesthesia
5. Evaluation for obstructive sleep apnea
6. Perioperative beta-blockers in noncardiac surgical patients
7. Reduction of postdural-puncture headaches with the use of pencil-point spinal needles
8. Management of postoperative hypothermia with forced-air convection system to restore
body temperature to 36°C (96.8°F)
9. Education about postoperative analgesic options and/or proper use of planned analgesic
regimen in adults
10. Implementation of a protocol to allow appropriate patients who are presenting for anes-
thesia to be able to ingest clear liquids up to 2 hours before the procedure
11. Treatment of postoperative shivering with meperidine

Adapted from www.asahq.org. Accessed December 30, 2007.

96 MARTINEZ

postdural-puncture headaches with the use of pencil-point spinal needles; 2) manage-

ment of postoperative hypothermia, defined as temperature less than 36°C on arrival
to the postanesthesia care unit, with an active warming device; 3) education about post-
operative analgesic options and/or proper use of planned analgesic regimen in adults;
4) implementation of a protocol to allow appropriate patients who are presenting for
anesthesia to be able to ingest clear liquids up to 2 hours before the procedure; and
5) treatment of postoperative shivering with meperidine.‡ These proposed measures
present the perioperative provider with many challenges from identifying the appro-
priate measurement tool and the financial burden of implementing such a program.
Despite the national focus on p4p and current implementation of programs across
clinical areas, there is little evidence that these initiatives will improve patient out-
comes.27 There is some modest evidence that p4p for select measures of quality, includ-
ing measures of care for heart failure, acute myocardial infarction, and pneumonia,
results in improvements in quality ranging form 2.6 to 4.1% over a 2-year period.28 There
is a growing body of literature that is evaluating these practices. It will be important to
evaluate the impact of implementation of endorsed quality practices and whether the
benefits of the p4p programs outweigh the costs of implementing sound measurement
and reporting systems.

Summary
Patient safety and quality improvement are important for all care providers and espe-
cially providers of anesthesia. Knowledge of the processes and outcomes that are being
highlighted nationally and identification of new areas for improvement are critical to
our role as perioperative caregivers. We must determine how to integrate the quality
improvement and data acquisition into our workflow to be successful because feedback
is imperative to success. Anesthesiology has long been acknowledged as a leader in
patient safety and the continued national highlight on improvement in patient safety
and quality offers leadership opportunities for the perioperative caregivers.

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‡Available at: www.asahq.org. Accessed December 30, 2007.

 ANESTHESIA AND PATIENT SAFETY 97

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