FDA Applauds APSF Efforts
New Royal College Meets, Studies Safety, Standards
Letters to the Editor
Editorial: Anesthesiologists' Malpractice Premiums Declining
Current Questions in Patient Safety
Society for Technology Organizes, Plans Future
Anesthesia Training Simulators Featured at Meeting
by Joseph S. Arcarese and Peter B. Carstensen
Four years ago this past September, officials of the U.S. Food and Drug Administration (FDA) were called to appear before a U.S. House of Representatives subcommittee on oversight and investigations to testify on anesthesia incidents and explain what the FDA had done to fulfill its responsibility to ensure that anesthesia machines were safe and effective. During that hearing, the Congressional subcommittee received testimony from more than one witness that thousands of Americans were dying each year as a consequence of anesthesia incidents and that most of these deaths appeared to be avoidable. It was further disclosed that these avoidable deaths were, for the most part, a consequence of human error and not a result of failure or malfunction of the equipment. These were disquieting revelations which clearly could not he left unaddressed.
In response, FDA witnesses testified that an education and information sharing program directed at anesthesia health care providers appeared to be needed and that FDA believed it could play a role in helping the anesthesia community implement such a program. FDA emphasized that for such a program to succeed, it was essential that it work in a cooperative and coordinated way with anesthesiologists and nurse anesthetists, rather than attempting to implement such a program unilaterally. The Congressional committee was also told that the FDA's Center for Devices and Radiological Health was prepared to devote significant resources to a long range program in this area.
FDA wasn't alone in its assessment of the need for a cooperative educational program. This was a conclusion already reached by the three major anesthesia machine manufacturers and most importantly, by the leadership of the ASA. Soon afterward, concerned health professionals working in conjunction with the ASA leadership took the initiative of organizing and chartering the Anesthesia Patient Safety Foundation (APSF) for the expressed purpose of "encouraging activities that wig prevent patients from being harmed by the effects of anesthesia."
In FDA's opinion, the APSF has done much to further the cause of anesthesia patient safety. The APSF has provided a needed forum in which manufacturers, health care professionals, malpractice insurance providers, government agencies and other interested parties could share information, ideas and concerns as well as identify activities and develop programs and approaches to improve patient safety. It was dear from the outset that all parties agreed that anesthesia needed to be safer and could be made safer, and that all parties had a major self interest in achieving this goal. The APSF has been especially effective in establishing and fostering a spirit of trust among these different parties. This is a trust without which effective cooperation would have been impossible.
The Foundation, through the APSF Aleu4efter has provided anesthesiologists and nurse anesthetists as well as other interested parties with useful, timely information and news specifically related to anesthesia patient safety. This is the only periodic publication of its kind solely dedicated to fulfilling this very important educational need. The Foundation has assured its wide distribution by mailing it to every anesthesiologist and nurse anesthetist in the U.S. whether they are APSF members or not.
The newsletter is not the only educational product of the Foundation. It has also produced three educational videotapes on patient safety, a much needed text on "Capnography" and one on "Safety and Cost Containment in Anesthesia".
The APSF's research grants program has made possible a number of important research studies in anesthesia patient safety Considering the modest dollar amounts of research funding which the Foundation has been able to contribute, the program is a remarkable success. The Foundation I& a great need in its support of research aimed specifically at patient safety. Unfortunately, it remains one of the few sources of support for such research.
Much has been accomplished to advance anesthesia patient safety over the past four years, and in large measure that progress can be traced to the Foundation's educational and research activities. Much, however, still remains to be doneIn FDA!s view, hospitals still need to be encouraged to upgrade equipment. There are far too many hospitals still operating with outdated anesthesia mach--Although many hospitals have purchased pulse oximeters, capnographs, and other modem monitoring equipment, many other hospitals have not yet taken advantage of this important way of helping to improve patient safety.
FDA is enthusiastic about the potential of anesthesia simulators and training aids to dramatically improve anesthesia training programs m the futureThe APSF, through its wwarch grants program and the activities of its Committee on Education and Trainms, is at the forefront in heipms to advance this promising new training modality.
It is FDA's hope and expectation that the APSF will continue to contribute to the advancement of anesthesia patient safety. The APSF serves as a model for other medical specialties seeking to improve the quality of medical care for their patients through a cooperative forum involving the health care professions, industry, government and other interested organizations.
Mr. Arcarese is Director, Office of Training and Assistance, Center for Devices and Radiologic Health, FDA, and Mr. Carstensen is Engineering Consultant in the same agency.
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by Dr. Jean Lumley
The Faculty of Anaesthetists of the Royal College of Surgeons of England achieved Collegiate status in October 1988. The Annual Symposium held in November therefore became the first Symposiurn of the College of Anaesthetists and it was appropriate that the topic addressed was "Safety and Standards in Anaesthesia".
The first speaker, Dr. I.N. Lunn from the University Hospital of Wales, commented that while the creation of standards for equipment for anaesthesia was not particularly easy, the matter of standards for anaesthesia organization and clinical matters had hardly yet been addressed. He went on to stress that surveys revealed the commonest source of mishap in anaesthesia is due to human failure.
Dr. E.C. Pierce from Harvard Medical School while reviewing critical incidents in anaesthesia, drawing attention to indications that anaesthesia related injuries, like aircraft accidents, do not usually result from isolated errors. Rather, anesthetic mishaps result from a combination of errors, system deficiencies, and predisposing influences that either help to create an environment conducive to error or a situation in which problems are not easily identified.
The medico-legal implications were discussed by Dr. M.J. Powers, Barrister at law, Temple. He suggested three means by which he believed that the numbers of medical claims could be drastically reduced. They were:
1. Recognition by the profession of the requirement for accountability to the patient, to the profession, and to the public.
2. A requirement for ongoing medical audit.
3. Introduction of minimal standards of anesthetic practice.
He congratulated the meeting on the way in which anaesthesia had led the way towards full medical audit with a degree of voluntary public accountability in the U.K.
The second session was devoted to a discussion of standards. Miss M.N. Duncan, Assistant Director, Safety and Quality Supplies from the Department of Health, talked about a decade of government activity in quality and standards. Since 1982, the government has pursued a policy of encouraging quality awareness in all sectors of industry, had taken part in a program of standards writing, and developed a registration scheme for manufacturers to be held to internationally recognized quality standards. She informed the meeting that for the next four years, a new goal in quality standards has been set in the decision to implement a single European market starting in 1992.
Dr. Peter Thompson from the University Hospital of Wales discussed the need for standards and described their history and development. He paid particular attention to the role of the International Electro Technical Committee (IEC) and the International Standards Organization OSO) in the standardization of anesthetic and related equipment. The role of the Test House run by the British Standards Institute in establishing test methods and reporting formats for electro-medical equipment was then discussed by Mr. N. Richardson, Principal Professional and Technology Officer, Department of Health. In addition to detailed testing and the preparation of formal reports, Test Houses offer half day consultations in which they have a thorough careful look at an item of equipment in conjunction with the manufacturer.
The third session was devoted to perspectives of design and function of anesthetic machines and ventilators. Dr. D. Wilkinson from St. Bartholomew's Hospital reviewed the evolution of the anesthetic machine and Dr. P.L. Jones from the University Hospital of Wales addressed the topic of future developments in this field. Mr. John Mecklenburgh, also from the University Hospital of Wales discussed current design standards of safety for ventilators and the requirement for efficient alarm systems. Professor I.G. Whitwam from the Royal Postgraduate Medical School reviewed ventilation techniques which may be available in the 1990's.
An interesting session was provided on electrical safety. The speakers were Mr. Mort Levin, previously with Hewlett Packard and Professor C.I. Hull from the Royal Victoria Hospital, Newcastle. It was stressed that achievement of safety is not a trivial task and concern was expressed that existing standards are not adequate. The second speaker discussed the implications of British Standards document 5724 which is concerned with the safe construction and operation of electro medical equipment. He compared the strengths and weaknesses of the standards by comparison with those adopted in other countries and stressed that safety can be maintained only by sensible use, constant of possible hazards, and an absolute refusal to "take chances" with faulty equipment.
The second day of the meeting opened with a session on essential monitoring with a talk given by Professor M.K. Sykes of the Radcliffe Infirmary, Oxford. He pointed out that two of the major tasks of the anaesthetist during an operation are 1) the monitoring of the function of the apparatus used to administer the anesthetic and 2) the monitoring of the patient's condition.
Role of Monitoring
Although recognizing that there was still no conclusive evidence that the use of monitoring devices results in reduction in morbidity or mortality, he discussed the circumstantial evidence that their use can contribute to safety. He drew attention to the Faculty of Anaesthetists' requirements for the provision of monitoring equipment in training establishments, published in 1987 and the Association of Anaesthetists' recommendations for standards of monitoring during anaesthesia and recovery, published in 1988.
Mr. P.J. Schreiber from North American Draeger told the audience that the designer of medical equipment had three measures involving integration of electronic monitoring available to prevent injury to a patient due to operator error. The first measure is to design the equipment in such a way that a human error cannot occur. The second measure is to design the equipment so that no injury results in the event that a human error occurs. The third measure is to warn of the human error and its consequences. While the first measure provides the highest degree of safety, it cannot always be utilized due to the widely varying uses medical and specifically anaesthesia equipment are put.
The sixth session included a talk on Safety aspects of personnel selection of pilots. This was given by Captain A.I.I. Butler, Manager of Flight Crew Training for British Airways. The qualities which British Airways considered necessary for selection into a cadet pilot program were described and the methods of selection were discussed. The larger part of the talk was devoted to the basic operating standards which have been established and the training of pilots to meet those standards, the monitoring of performance, the recurrent training necessary, and the personnel and equipment used in the process of ensuring air safety through the training. In spite of all these safeguards, Captain Butler remarked that 80% of accidents have a human error element.
Psychology of Error
My-. 1. Chappolow from the RAF Institute of Aviation Medicine, talked about the psychology of human error; his analysis was based largely on investigations of aviation accidents. Fatigue was noted to play a part in only 9% of accidents and the effects of stress or personality and accident proneness are not clear cut. Mr. Chappelow said that 40% of human errors included equipment designed errors, inadequacy in training, and failure in administrative support or supervision.
The final session was devoted to equipment management. Mr. B.J. Love, Assistant Director from the Department of Health's Procurement Directorate, described the purchasing strategies advocated by the Department of Health. He made a plea for buyers to be specialists in their knowledge of the marketplace and hoped that the development of national centers of responsibility for procurement would provide a national focus and locus for acquiring this expertise. In this way it was hoped that closer partnerships would be found between the National Health Service and its suppliers in both the technical and commercial field. Mr. L.F.G. Small, Principal Procurement Technical Officer to the Supplies Technology Division, Department of Health, talked of the investigations of equipment accidents which had been undertaken for more than 25 years. He mentioned a Health Equipment Information Bulletin on equipment management whose implementation has considerably reduced the incidents of equipment failure He stressed that the purpose of equipment management is to ensure that the right equipment is available when required in a safe and serviceable condition.
Dr. J. Lumley, from the Royal Post Graduate Medical School, talked of the acceptance procedures necessary when new equipment has been purchased. She also recommended that great care should be undertaken when accepting equipment back into service after maintenance, whether in-house or out-of-house servicing had been undertaken.
The final talk of the day was a lateral view of safety or risks and at what cost to the public by Mr. Anthony Smith, writer and broadcaster. Again a plea was made to the profession to educate the public. The overall theme which emerged from the meeting was that in terms of safety for patients, user (both physician and patient) education is all important.
Dr. Lumley is Consultant and Honorary Senior Lecturer, Royal Postgraduate Medical School, Hamnersmith Hospital, London.
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Risk Manager Notes Improvement in Anesthesia Losses
To the Editor:
In reading the APSF Newsletter, I was struck by how far the discipline of anesthesia has come, particularly in the past five years. I speak not as a clinician, but as a provider of professional liability insurance for over 5,000 physicians in the Harvard system. The results of intensive patient safety activities within the specialty have been, in my opinion, nothing short of remarkable. There is little doubt in my mind that the concerted efforts of the Anesthesia Patient Safety Foundation and its members have largely contributed to the creation of crucial risk management and quality assurance activities in hospitals throughout the country.
All of this, along with improved loss experience among anesthesiologists, is now translating into lower malpractice rates and discounted premiums in many parts of the country. Within the Harvard malpractice insurance program, the premium relativities used in determining the differences among various physician risk categories are being reduced for the third consecutive yew in anesthesiology. This means that effective our new policy year beginning April 1, 1989, anesthesiologists (Premium Class 3) will be paying only half of what they would have been assessed in their old 1985 rating group (Premium Class 5). And when factoring in an "across-the-board" Harvard premium reduction for all specialties in 1989, anesthesiologist's total premiums will drop by 33% over the 1988 rate! It should be noted that the Department of Anesthesia at Harvard Medical School has been developing and using clinical standards since 1985. These standards are based, in part, on 13 years of historical loss experience for the specialty.
Without benefit of scientific analysis, I am confident in saying that this favorable trend toward improved patient safety would not have taken place absent the invaluable contributions of the Anesthesia Patient Safety Foundation and the membership of the American Society of Anesthesiologists.
As an insurance "outsider" looking in, I can only hope that other clinical specialties find the same encouragement and technical resources that organizations like APSF and ASA have provided to the field of anesthesia. It is my hope that the APSF will continue to serve as a catalyst and valuable resource for strong risk management/ patient safety innovations.
James E Holzer, J.D.
Vice President, Risk Management Foundation Cambridge,
Letters to the Editor:
Anesthesia Applauded; CA Insurance Rates Fall
To the Editor:
As a practicing surgeon and medical director, as well as board member of The Doctors' Company, I write to commend your specialty leadership for your superlative ongoing effort on behalf of anesthesia claims prevention. Our company, the largest independent doctor-owned liability carrier, insures the largest block of anesthesiologists in California and a growing number in six other states.
We look to anesthesia as a shining example of what can be done if a group of high risk specialists makes a concerted assault on claim frequency and severity. In our company, anesthesia premium levels have dropped two whole classes in the past few years because of the remarkable track record achieved by your group. The "bottom line" is that if you can do it, so can others. Keep up the good work.
Mark Gomey, M.D., Medical Director, The Doctors' Management Company, Santa Monica, CA
Prevention of Accidental IV Injection into Epidural Tubing
To the Editor:
In the perioperative period, patients usually have one or more intravenous infusions. Furthermore continuous epidural infusion of local anesthetics or narcotics is becoming an increasing popular practice for providing adequate analgesia for labor as well as for postoperative surgical pain relief. When using this technique, intravenous tubing is connected to a pump and is attached to the end of an epidural catheter.
Drugs like thiopental (1), magnesium sulfate (2), and potassium chloride (3) have been injected into the epidural space through the wrong tubing by accident. To prevent such accidents, different methods have been suggested: e.g. wrapping of tape on all injection ports(2), special continuous infusion sets without injection ports (4), or use of rigid pressure tubing without any ports (5). However, many large hospitals have contracts for specific infusion pumps and infusion sets for continuous epidural infusion for lengthy periods of time and, for economic reasons, practitioners must use the available pump and the tubing set that has intravenous injection ports.
Figure 1. Intact Monoject needle on left and standard
I.V. tubing injection port.
Figure 2. Cap from Monoject needle removed and used to cover and thus protect injection port in tubing connected to epidural catheter.
We report another simple method of covering injection ports which should help to reduce the incidence of accidental injection of unintended and potentially dangerous drugs into the epidural space
The standard Monoject hypodermic needle comes in a plastic container as shown in Figure 1. The upper white part (cap) of the needle container is detached easily and this cap fits snugly on standard injection ports as shown in Figure 2. We use this method to protect the tubing ports on continuous epidural infusions from accidental injection.
Intraoperatively, this method of protecting injection ports can also be useful. It is common for anesthetists to attach I.V. tubing to precordial stethoscopes to listen to breath sounds. This extension tubing usually also has two injection ports. It is our clinical impression that an occasional drug intended for intravenous infusion has been accidentally injected into the injection port of the stethoscope tubing instead of the patient's I.V. fine injection ports. This needle cap placed on these ports in the stethoscope tubing may prevent these accidents as well as the more serious ones involving epidural catheters.
Mushtaque M. Juneja, M.D., EEA.R.C.S., William E. Ackerman, M.D., Department of Anesthesia, University of Cincinnati College of Medicine, Cincinnati, Ohio
1. Forester JE, Raj PP. Inadvertent epidural injection of thiopental: a case report. Anesth Analg 1975: 406-7.
2. Dror A, Henriksen E. Accidental epidural magnesium sulfate injection. Anesth Analg 1987: 66:1020-1.
3. Lin D, Becker K, Shapiro HM. Neurologic changes following epidural injection of potassium chloride and diazepam: a case report with laboratory correlation. Anesthesiology 1986: 65:210-2.
4. Fromme Ga, Atchison SR. Safety of continuous epidural infusions (Letter). Anesthesiology 1987. 66:94.
5. Zylanoff P. Safe continuous epidural infusions (Letter). Anesthesiology 1987: 66:94-5.
Letters to the Editor: Return to Simpler Techniques Urged
Complexity, Technology Seen as Possible Problems
To the Editor:
I enjoy reading the issues of the APSF Newsletter which have been (so far) reaching me with unfailing regularity. But the general tenor disturbs me because the remedies espoused seem invariably to involve the use of more complex instrumentation, more rigid codes of practice, and escalating expenditure of time, energy, and money. These factors militate against universal acceptance and, hence, success in the objectives sought.
Here I draw a parallel between human behavior and the AIDS epidemic. Universal self-discipline at the sexual level might well have prevented the epidemic and could perhaps control it. However, at the moment, the only reasonably effective way of containing the spread of the virus seems to be the use of a condom when personal self-discipline is wanting. The condom is cheap and it most certainly is not a modern invention.
Anesthetic mortality (and morbidity a vast iceberg, the invisible part of which is as yet largely unexplored) is not new and much of it is due to our failure to understand that anesthesia clinicians cannot totally control the physiology and responses of their patients.
Anesthesiologists who think that they have all the answers to their patients' problems are kidding themselves and potentially killing those patients!
But if anesthesiologists will admit that any action they take may have randomly-occuring, unwanted, and sometimes dangerous or fatal outcomes, then they can make use of statistical mathematical aids which can point the safest way through an anesthetic maze. Also, this way will usually he the simplest and the least expensive dollar-wise! What is needed to promote patient-safety is not a proliferation of fallible artificial monitors, but the development of simpler and safer basic procedures!
For example, I reported in 1961 that disregarding our forefathers' dictum. "Don't give a muscle relaxant until your endotracheal tube is in the correct place!" had led to the death of four and the permanent disability of two patients.
In 1976 and again in 1982 and 1984, 1 drew attention to the demand-feed anesthetic technique which was pioneered by McKesson in 19 10 and which dispenses a pre-selected anesthetic atmosphere, by-passing the need for trying to monitor the composition of the mixture that the patient is inhaling. It also prevents any carbon dioxide accumulation either in the circuit (by voiding all exhaled gases to atmosphere) or in the patient (by assisting respiratory efforts or taking them over).
The evidence that our specialty needs to alter radically its present approach to the mechanics of inhalational anesthesia is all them But the will to re-think present practices seem to be paralyzed. We seem to be hypnotized by a belief in our own wisdom. According to Al Koran, no folly is greater than this.
Dr. C. Stanley Jones Worcester, C.P.
Republic of South Africa
Letters to the Editor: Still More on Briefly Leaving Patient
Editor's note: In the December issue, Dr. Miguel Figueroa's letter to the Editor questioned Dr. Zauder's statement that an anesthetized patient should never be left unattended and presented a hypothetical case of a sudden PACU emergency requiring intervention by an anesthesiologist.
Dr. Zauder responds:
Provocative as ever, Doctor Figueroa raises a major moral, ethical and legal issue. I am amazed that this renowned semanticist has allowed h4nself to fall into such a trap. He is providing Monitored Anesthesia Care. The patient is "slightly sedated but awake and perfectly calm even trying to talk whenever she is allowed". Both Doctor Jenne and I were emphatic about not leaving an anesthetized patient. Is a slightly sedated but awake patient anesthetized? I think not. Doctor Figueroa's action, then, was appropriate.
Suppose the scenario is changed just a bit. Jenne refuses to have her cataract extracted under local anesthesia. Figueroa administers a general anesthetic. The recovery room calls to say Zauder having been extubated "was experiencing some respiratory obstructions. Figueroa rushes to the PARR. Jenne's anesthesia lightens. She "bucks" on the tube and extrudes vitreous. Belli is retained and charges abandonment. What is the defense? There is none!
Change the scenario once again. Figueroa elects to remain with Jenne. Zander is brain damaged. His family retains Spence who consults the ICAHO He learns about SA 1.18A which states. "a licensed independent practitioner qualified in resuscitative techniques is present or immediately available until all patients operated on each day have been evaluated and discharged". Spence institutes suit charging the facility and all who work therein have faded to adhere to the recommendations of the ICAHO. His case revolves about the definition of "immediately available' He contends that one who is providing anesthetic care is not immediately available to care for another patient.
Howard L. Zauder, M.D., Ph.D. Albuquerque, N.M.
Plea for Best Judgment on Stepping Out of Room
To the Editor:
Re: recent discussions of the propriety of an anesthesiologist stepping out of the operating room. The responses of Drs. Zauder and Jenne stating never are just absurd. No one would condone abandoning a patient. However common sense needs to enter here somewhere As in all aspects of our practices, JUDGEMENT based upon individual circumstances is key.
Are we really to believe that the anesthesiologist who properly monitors his/her patient with auditory and visual (and recorded) data is condemned if he/she steps just outside the door to avoid total body repetitive x-rays? Or condemned if when splattered with blood steps outside the OR door to wash off the nasty stuff while observing his/her patient/monitors through a glass window? PURE FANTASY! Under such conditions, with a stable patient, those actions are prudent and appropriate, not indicative of neglect. Judgement, gentlemen. (We are not talking about leaving the patient to go sit in the lounge!)
Dr. Figueroa's story was fun. And he was right! If faced with his predicament, I would do the same, and sleep well at night. There is no
"never" to this question facts and circumstances, folks. Woe the day when there is no flexibility in our lives to take the best care of all of our patient. Re-think this one, guys.
Richard P. Fogdall, M.D. Friant, CA
Letters to the Editor:
Care Team Approach Cited as Possibly Safer
To the Editor:
I am delighted to see the relationship between anesthesia patient safety and the anesthesia care team begin to be documented through the efforts of the Foundation and your readers' correspondence. There are few situations where the presence of a second brain and pair of hands is not helpful in an anesthetizing location, if only to ensure the expeditious placement, accuracy, and documentation of required physical monitoring techniques.
The aeronautic analogy to anesthesia is well founded in clinical practice, and the presence of a co pilot is dictated by demands of the system. The primary care-giver, whether anesthesiologist or anesthetist, is always occupied by constant vigilance of available clinical and physical data, and is in a poor position to analyze long-term trends. The secondary care-giver is in a much better position to see the forest rather than the individual fix2s or the destination of the flight rather than the altitude, ground speed, and fuel status of the aeroplane. Many clinical situations demand a joint, synergistic relationship between two providers, especially since we are dealing with increasing numbers of elderly, complex patients. Unlike routine flights, every patient procedure is a journey into the unknown.
Many of the arguments against a very fulfilling team relationship between anesthesiologists and anesthetists have been facile turf battles with a strong economic bias and have largely ignored the right of the patient to the best possible care. The leadership of the two professional organizations purporting to represent the interests of the specialty of anesthesia have so antagonized each other that those of us who have invested a great deal of effort in budding the anesthesia care team concept have little faith in their perception of the real world of anesthesia. As Dr. Mundy suggested in his September letter, we must study the differences in safety between solo physician and team care anesthesia. Economic arguments have no place in dictation of standards of care.
L. Andrew Rauscher, M.D., Chief, Department of Anesthesiology,
The Mary Imogene Bassett Hospital, Cooperstown, New York.
Dangers of Midazolam Tell your Friends!
To the Editor:
A recent article from the California Society of Anesthesiologists BULLETIN underscored the danger of respiratory depression, morbidity, and mortality while using the remarkably effective and very useful drug, midazolam.
This letter asks all anesthesiologists to be personally vigilant when using midazolam and to inform colleagues (endoscopist, dentists, etc.) concerning the appropriate dosage and potential hazards of midazolam.
Bernard D. Morgan, M.D., Chairman Committee on Standards
California Society of anesthesiologists
Midazolam: Can We Help?
As anesthesiologists, we believe that improved observation skills and better monitoring equipment will help to prevent mishaps during the administration of intravenous sedative and narcotic drugs. Also, we have, in the last ten years, witnessed the development of increasingly potent and effective anxiolytics and analgesics. Additionally, we have experienced the recent advances in the capability of modem anesthesia patient monitoring equipment. It is no wonder then, that anesthesiologists are uniquely qualified to both correctly administer these sophisticated new drugs and to interpret modem anesthesia patient monitoring equipment to optimize patient safety.
Recent articles in the San Francisco Chronicle and the Wall Street Journal have focused on excessive sedation, respiratory and cardiac arrests, and death associated with the administration of Versed (Midazolam). Testimony at the House subcommittee on Human Resources and Intergovernmental Relations, which oversees the FDA., implied that these mishaps could have been avoided through better testing and regulating of the drug. On the other hand, Dr. Carl Peck, director of the F.D.A.'s Center for Drug Evaluation and Research, told the hearing that "the F.D.A.'s approval of Midazolam in 1985 was appropriate and that initial dosing recommendations were supported by the data available at the time!'
Instead of fixing the blame, we should focus on fixing the problem. While it is true that early detection of an incident by monitors will not necessarily result in successful recovery, it is accepted that early intervention in episodes of hypoxemia, hypotension, or cardiac dysrhythmia will improve outcome significantly. Presumably, many of the reported deaths associated with the administration of Midazolam could have been prevented if the drug dosage was carefully titrated and the patient appropriately monitored.
That is where we as anesthesiologists come in. It is our responsibility to offer our expertise in the administration of Midazolam and in monitoring patients to non-anesthesiologists who are using this drug. This clearly is an opportunity to influence the quality of care a patient receives and at the same time contribute to the education of our colleagues. Sharing our knowledge and experience reinforces the dosage and administration guidelines for I.V. conscious sedation published by Roche, the manufacturer of Midazolam. It also enhances our position as the physician specialty most knowledgeable about the pharmacology, pharmacokinetics, and pharmacodynamics of I.V. anesthetic drugs.
Seek out those specialists who are likely to use I.V. Midazolam for its anxiolytic or amnestic effect (gastroenterologists, cardiologists, urologists, plastic surgeons, etc.), and help them use the drug more effectively and safely Remind them that the potency was underestimated when the drug was first introduced and has now been revised so that compared with diazopam on a mg. per mg. basis, Midazolam is at least four times as potent. Help them to understand that reductions by 30% in recommended doses are suggested for patients over 60 years of age or when narcotics are given concomitantly or as a premedication; and additional reductions by a total of 60% of the recommended dose are appropriate for de-debilitated patients. Emphasize that Midazolam must never be used without individualization of dosage Warn them that the immediate availability of oxygen, resuscitative equipment, and skilled personnel for the maintenance of a patient airway and support of ventilation should be ensured prior to the administration of Midazolam in any dose. Explain to your colleagues how to titrate slowly (over 2 to 3 minutes) and carefully incremental doses of I.V. Midazolam with appropriate monitors applied to the patient and a vigilant observer dedicated to watching same.
While successful intervention in the chain of Midazolam mishap evolution cannot be guaranteed, the odds can be improved by sophisticated and informed administration of the drug, including careful monitoring of the patients for early signs of hypoventilation or apnea which can lead to hypoxemia or cardiac arrest unless effective countermeasures are taken immediately.
Clearly, there should also be immediate availability of
resuscitative drugs and equipment and personnel trained in their use to
further improve the probability of successful intervention. Get involved,
and you wig be rendering a service to your colleagues and their patients
which will generate respect and appreciation for you and for your chosen
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Editorial: Anesthesiologists' Malpractice Premiums Declining
There is little good news for hospitals and physicians from any quarter the-se days. However, premium costs for anesthesiologists are easing at the two major insurance companies in Massachusetts and nationally at the St. Paul Fire & Marine Insurance Company. In recent years, the relative rate factor (classification) for anesthesiologists at St. Paul has declined from 5.0 to 3.5, at the Massachusetts Joint Underwriting Association UUA) from 5.0 to 3.5 (soon to go to 3.0), and at Harvard's insurer, CRICO from 5.0 to 3.0. This classification is one indication of relativity, or the multiplication factor applied to the lowest malpractice premium (usually family practitioners who do no surgery) to determine the premium for each class of specialists.
Relative rate changes are not necessarily accompanied by equal changes in the premium cost because the base may change However, in the case of CRICO, the actual premium costs have declined by 33% for 1989 compared to 1988. Furthermore, in the JUA, whereas there were 27 major hypoxic claim in the I 8 months prior to December 31, 1986, during the calendar year 1988 not a single one was reported. Similarly among the CRICO insureds, there has not been a single major intraoperative catastrophic anesthesia mishap in some 280,000 anesthetics since August, 1985.
In the NAIC study during the 1970's of malpractice claims, anesthesia accounted for about 3.5% of the total number of malpractice claims; the associated cost of anesthesia-induced claim VMS about 11% of the total cost. Today at St. Paul, the number of claims remains at 3.5% but the total cost has fallen to 3.6% suggesting that the average type of claim now is due to problems and injuries that are less severe.
In this issue of the Newsletter, James F. Holzer, J.D., Vice President for Risk Management at CRICO gives his viewpoint. Earlier, Mr. William A. Cass, Risk Manager at the JUA, commented "They've made the practice of anesthesia a low risk procedures"
Across the country, and indeed around the world, the causes for such changes are hotly debated. We may never know the precise reasons. However, I personally agree with Holzer and Cass in believing that the setting of standards and the utilization of specific fail safe backup monitoring devices is responsible to a considerable extent. Not all people examining the phenomenon concur. Other factors should be considered: improved training and education, recognition of human error, more qualified and better practitioners, more advanced departmental organization, and markedly increased interest in all aspects of risk management. Perhaps in time it will be sorted out. In any case, the markedly improved claims experience is here now and is good news for all involved.
E.C. Pierce, Jr. M.D. President, APSF
1. McGinn, PR: Practice standards leading to premium reductions.
American Medical News, December 2, 1988;22.
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Question: I have been hired by physician anesthesiologists who request that I wash and reuse supposedly disposable single-use equipment such as endotracheal tubes and breathing circuits. What is the current standard of practice on this issue and what are the safety and liability implications of doing this? A CRNA
Answer: Safety, liability, and cost-effectiveness must be addressed in determining whether to reuse a medical device which has been designed and manufactured for one-time use. The American Society for Hospital Central Service Personnel has published Guidelines for the Reuse of Disposable Medical Devices with the objective of establishing procedures to ascertain whether any device labeled "single-use-only" can be adequately reprocessed' (1) These guidelines are only an outline of considerations for the development of future policies and procedures. The issue of whether and when to reprocess a single-use device has yet to be resolved by consensus.
Greene has reported the results of an informal survey taken at the International Conference on the Reuse of Disposable Medical Devices (2) Two hundred and four respondents reported 44 disposable devices as being correctly reused, with hemodialyzers, cardiovascular catheters and guide wires, respiratory therapy breathing circuits, biopsy needles, cautery devices, anesthesia breathing circuits and endotracheal tubes being cited most often (3)
In a review of reuse of disposable devices at the Medical College of Virginia (4) , Mayhall has pointed out the risks associated with reuse of both anesthesia and respiratory therapy face masks, corrugated tubing and bags, airways and esophageal stethoscopes. Ethylene oxide sterilization can present a major hazard to the structural integrity of a device intended for single use, and the activated glutaraldehyds used to disinfect breathing circuits has been linked to tracheal burns (4)
In 1987, Health and We4fare Canada published the results of a survey of all Canadian Hospitals taken to determine the orient of re" of disposable equipment which showed 41% of Canadian hospitals reusing equipment intended for one-time uses, with this practice significantly more frequent in those hospitals with 200 or More beds (5). Lamentably, of the hospitals responding, only 38% used written reprocessing procedures, 68% could not provide records of the number of times an item was used, and only 29% had made any assessment of cost effectiveness. Of 165 hospitals classified as "regular reusers" (200 or more beds), 70% reused Bain circuits, 7 1 % nebulizers-humidifiers, 13% endotracheal tubes, 58% other breathing circuits, 8% transducer domes, 20% cardiac catheters and 8% arterial catheter needles(5). No specific court cases were reported from Canadian courts involving reuse of disposable medical devices, but a number of Canadian product liability cases dealt with the user's failure to comply with manufacturer's instructions.
The FDA Cites Lack of Data Supporting Reusing Disposables
The U.S. Food and Drug Administration (FDA), in its Compliance Policy Guide of September 24, 1987, states that "there is a lack of data to support the general reuse of disposable medical devices, including disposable guide wires and catheters. The fact that devices are labeled disposable is indicative of this lack of data. In order for a device to be considered 'reusable', it must be capable of withstanding necessary cleanings and restorative techniques and methods, and continue to be safe and reliable for its intended use (6). By definition, a disposable device is not intended by the manufacturer to be reused, so that, "Any institution or practitioner who resterilizes and/or reuses a disposable medical device must bear all responsibility for its safety and effectiveness (6). This FDA statement must control anesthetists' current practice habits.
ASTM Backs FDA Stand
In recognition of the need to address this issue, in September of 1986, ASTM's Committee F-04 on Medical and Surgical Materials and Devices organized a Subcommittee F-04.20 on Reprocessing of Medical Devices. Taking a position in conformance with the FDA's stance that the manufacturer is responsible only for the safety and effectiveness of a device at its initial use, unless the device is clearly Libeled and designated as intended for multiple use, and that the reprocessor is responsible for reuse, Subcommittee "4.02, chaired by Mr. M.L. Bancroft of Harvard University, is currently developing a guideline document for the use of physicians, nurses, administrators, insurance carriers, patients and others for whom this question has become a significant concern.
In conformance with definitions established by the Centers for Disease Control (7)., "critical" devices are those which enter the vascular, circulatory, or central nervous systems, or any sterile cavity, "semi-critical", those which come in contact with mucous membranes or enter a sterile cavity while passing through a non-sterile area, and "non-critical", those which come into contact with intact skin. As Radany et. al. have pointed out (8) the monitoring of and adherence to such distinctions by nurses will be a major factor in the success or any reprocessing program.
The reuse of CDC classified critical or semicritical single-use medical devices is fraught with hazard. ASTM's Subcommittee on Reprocessing of Medical Devices believes that it is obligatory for the manufacturer of a device intended for multiple use to provide the user with an adequately tested reprocessing protocol, as well as the actual test procedure and results. The Committee is taking a firm stance on adherence to recommended procedures by personnel responsible for reprocessing.
The reuse of disposable anesthesia devices presents a greater medicolegal hazard than other types of equipment, commensurate with the relative size of malpractice awards in anesthesiology. Consequently, anesthesia devices intended for single use are not reused in Harvard Medical School's system of teaching hospitals (9).
In formulating a decision to reutilize a device intended for one-time use, the end-user must consider the overall quality of the sterilization/ reconditioning facilities available and his/her availability to supervise or personally undertake the reprocessing and subsequent reinspection. Written protocols for the sterilization and reconditioning must be acceptable to the manufacturer, the insurers, and the physician dispenser, for the decision to reuse an anesthesia device intended for single use is a medical one, with the attending anesthesiologist ultimately responsible for its outcome. As should be the case with the use of any controversial drug or treatment, the decision to employ a reprocessed single-use item should be communicated by the anesthesiologist or his representative to appropriate non-physician staff by written policy memorandum agreed upon by the hospital administration. At the same time, it is incumbent on the CRNA or other non-physician staff member to voice his argument against the use of a particular reprocessed device in writing to an appropriate authority, even though he agrees to proceed as instructed (Table 1).
Table I Reuse of Disposable Anesthesia Equipment Physician Checklist
Will the reuse program conform to FDA guidelines?
Does the Anesthesiology Department have written policy and procedures on the reuse of disposable equipment? Has the hospital administration approved these procedures in writing?
Have the sterilization/reconditioning procedures specified been adequately tested, and has a regular review program been established?
Does the liability insurance document accurately reflect hospital departrnental policy on reuse?
Does the anesthesia equipment conform to ISO and ASTM standards?
Have the CRNAs and other appropriate
non-physician personnel agreed in writing to the reuse policies and procedures?
Answer provided by Ms. Debra Milamed, M.S. and John Heffley-Whyte M.D.; Department of Health Policy and Management; Harvard School of Public Health at the VA Medical Center; Boston, MA 02132.
1. American Society for Hospital Central Service Personnel. Guidelines for the reuse of disposable medical devices. Infed. Control 7(11): 562, 1986.
2. The Institute for Health Policy Analysis, Georgetown University Medical Center: Reuse of Disposable Medical Devices in the 1980's. Proceedings of an International Conference, March 29-30, 1984, Washington, D.C. Washington, D.C.: Institute for Health Policy Analysis, Georgetown University Medical Center, 1984.
3. Greene, VW.: Reuse of disposable medical devices; historical and current aspects. Infect. Control 7(10): 508-513, 1986.
4. Mayhall, C.G.: Types of disposable medical devices reused in hospitals. Infect Control 15(5): 196-200, 1987.
5. Campbell, BLA., Wells, G.A., Palmer, W.N., and Martin, D.L.: Reuse of disposable medical devices in Canadian hospitals. Am. 1. Infection Control 15(5): 196-200, 1987.
6. Food and Drug Administration. Office of Enforcement, Division of Compliance Policy. Associate Commissioner for Regulatory Affairs. Compliance Policy Guide 7124.16. Washington, D.C.: U.S. Government Printing Office, September 24, 1987.
7. Centers for Disease Control. Center for Infectious Diseases, Hospital Infections Program. Guidelines for Handwashing and Hospital Environmental Control.
8. Radany, M., Perry, S., and McCallum, D.: Is it safe to reuse disposables Am. 1. Nursing 87(l): 35-38, 1987.
9. Hedley-Whyte, I.: Medicolegal and infection risks of reuse of single-use supplies and equipment in anesthesiology. In Reuse of Disposable Medical Devices in the 1980s. Proceedings of an International Conference, March 29-30, 1984, Washington, D.C. Washington, D.C.: Institute for Health Policy Analysis, Georgetown Medical Center, 1984, p. 149-155.
10. Springfield, V.A.: National Technical Information
Service (PB85-923404), 1985.
Current Questions in Patient Safety: OB
Question: In our 300-bed hospital, we have about 550 OB anesthetics per year. Obstetricians are objecting to our policy of refusing to institute epidural analgesia for labor unless there is a qualified obstetrician actually in the labor suite and who will stay throughout the labor. What is the current standard of safe anesthetic practice?
Answer: The Joint Statement on the Optimal Goals for Anesthesia Care in Obstetrics, issued in 1988 by the American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists addresses this issue quite dearly. Paragraph V reads as follows:
"Availability of a qualified obstetrician during administration of anesthesia. Major conduction anesthesia (epidural, caudal or spinal) and/or general anesthesia should not be administered until the patient has been examined, and the fetal status and progress of labor evaluated by a qualified physician who is readily available to supervise the labor and to deal with any obstetric complications that may arise".
Thus, although the obstetrician is not required to be physically present in the Delivery Suite throughout the conduct of epidural anesthesia, he should be close enough and capable of responding effectively to any obstetric emergency.
Answer by M. Finster, M.D.; Professor of Anesthesiology, Obstetrics and Gynecology, Columbia University, New York.
In 1866, the obstetrician probably was in attendance when
this self-administered Ether-Chloroform-Alcohol vaporizer was in use for
labor discomfort. Illustration courtesy of the Wood Library-Museum, American
Society of Anesthesiologists.
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by N. Ty Smith, M.D.
A new society the Society for Technology in Anesthesia (STA) has been recently formed.
Technology and patient safety are inexorably intertwined. However, the rapid changes in technology and in clinical standards have created a difficult situation for the clinician. We cannot observe, much less record or assimilate, all of the information that is becoming avadable. We therefore increasingly depend on technology to help as hopefully in the form of better anesthesia machines, ventilators and monitors. But using all of these new and complex devices has not been easy for most clinicians. Most clinicians have not been trained to deal with technology. Most engineers and technicians have not been trained to deal with clinicians.
The need for communication and education among those interested in medical technology is real. The American Society of Anesthesiologists (ASA) has dealt with these matters m several ways, including a Committee on Patient Safety and Risk Management, a Committee on Standards of Cam a Subcommittee on Equipment, Monitoring and Engineering Technology, and diverse presentations at the ASA Annual Meeting, including scientific papers, panels, and refresher course lectures. The widely recognized Anesthesia Patient Safety Foundation has managed to call the attention of the anesthetist to the role of terminology m patient safety, primarily through its newsletter, but also through other educational ventures. The journal of Clinical Monitoring has made it possible to archive and formalize the communication among those interested in medical technology.
A less formal, but still structured, means of communication is still needed, however hence the society. By setting up several different lines of communication, STA will allow a greater number of people to have a larger say in the progress of medical technology. It will also facilitate contact among those of similar interests.
6:00 A.M. Enthusiasm
With this in mind, a feasibility and planning meeting was held at the last ASA meeting in San Francisco. The fifty who were able to attend the 6:00 a.m. meeting agreed that such a society is needed. The enthusiasm for a new society was so overwhelming that an organizational structure was set up, including officers and a Board of Directors. These included President, Ty Smith; Vice President, Allen Ream; Secretary, Frank Block, Jr.; Treasurer, Alan Grogono; and Directors, Jerry Calkins, Bob Chilcoat, and J.S. Gravenstein. it was also decided that the relationship with the ASA would be one of mutual assistance and consultation. Those present at the meeting felt that STA should be 1) clinically oriented, 2) international in scope, 3) open to all interested parties, 4) have broad interests but a narrow name, and 5) welcome clinically, technically, and industrially oriented members.
There are several benefits to the Society in addition to the opportunity to communicate with others interested in technology. These benefits include a newsletter, a subscription to the Journal of Clinical Monitoring, and access to the ICM Readers Group Bulletin Board, via the Delphi computer link. Access to the bulletin board will allow access to messages, announcements, news, computer programs, information files, etc. Those interested in further information on the possibility should refer to a description of the journal of Clinical Monitoring Readers Group. Block, E, On-fine telecomrnunications: The ICM Readers Group on Delphi. J. clin monit 2:140-141, 1986.
The interests of the Society are widespread and include all of the subspecialties of anesthesia and critical cam It also can involve anyone interested in medical technology. Accordingly, STA plans to maintain close relationships with other societies, either as a component society or as a parent to other component societies.
Events are already forthcoming for STA. Be sure to plan now for these, especially at the ASA Meeting in New Orleans, October 14-18, 1989. On late Saturday afternoon and Saturday night, October 14, there will be a Charter Member meeting that will feature an invited speaker, a discussion of the permanent by-laws, a discussion of future directions for STA, and related subjects. Those who join STA before or during that meeting will become Charter Members. Because we had difficulty contacting many of the people who will be interested in STA, we hope that attendance at the meeting will be more representative than that at the initial 1988 meeting.
Also at the ASA meeting, on Wednesday morning, October 18, there will be the Society's first breakfast panel. The theme is a debate on who should take credit for improved patient safety the dini6an, the educator, the monitors, the APSF, the standards makers ...
Further ahead is the first annual meeting sponsored by STA, to be held in 1990. As soon as a date and place are finned up, announcements will be printed in this Newsletter.
In spite of the restrictive sounding name, membership is open to anyone who is interested in medical technology whether exploring it, teaching it, learning about it, or exchanging ideas. If you are interested in joining STA, write or call: Frank E. Block, Jr., M.D.; Secretary, STA; Anesthesiology, N-429; Ohio State University; 410 West 10th Avenue; Columbus, OH 43210-1228. Also look for further information on STA in future issues of the APSF Newsletter.
In the meantime, if you have any questions or thoughts about STA, please contact any one of the Board of Directors.
Dr. Smith, V.A. Media Center, San Diego, is President
of the STA and an APSF Director.
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by J.S. Gravenstein, M.D.
With the help of realistic simulators and computer training devices, an anesthesia trainee can practice procedures simultaneously requiring both the quick recognition of concepts and also dexterity.
The Food and Drug Administration (FDA) and the anesthesia Patient Safety Foundation (APSF) have often stressed that safety in anesthesia depends most heavily upon the clinician in the operating room and secondarily on the instruments with which the clinician works. Education of the practitioner, therefore is a major concern for both organizations. Modem instructional techniques ran greatly facilitate learning by enabling the student to visualize complex concepts with the help of sophisticated computer programs and by making simulators available.
Several investigators have developed training devices and simulators offering excellent instruction to students of anesthesiology. However, these training devices and simulators exist almost exclusively at their development sites. A wider recognition of their advantages, the FDA and the APSF argued, can stimulate a wider adoption of these modem instructional devices. Toward this end, the two organizations sponsored a workshop in Chicago on September 9 and 10, 1988 at which eight investigators displayed anesthesia training devices and simulators (supported by FDA Grant #FD-R-000420-01).
Twenty-one anesthesiologist educators from around the U.S. were invited to become acquainted with these modem educational tools.
After the workshop, the educators provided written evaluations of what they had learned. Following are excerpts (in alphabetical order of principal investigator).
Gas Uptake Simulation (G.U.S.) Developed by: Jerry M. Calkins, M.D. and Jeffrey Spain, M.D.; Maricopa Medical Center, Phoenix, AZ: "It's a computer program teaching and testing one's understanding of uptake and distribution of volatile agents. The mouse-driven version has good pulldown menus, easy entry and start-up, clear windows, and excellent graphs. G.U.S. is fun to play, interactive enough to hold your attention, and far superior to 'book learning' alone I will be getting this program to teach our own resident group."
Comprehensive Anesthesia Simulator Environment (CASE) Developed by: David M. Gaba, M.D. and Abe DeAnda, B.S.; Anesthesia Service, Palo Alto, CA: "This system recreates a patient-centered, anesthesia machine-driven operating room environment in which a trainee is presented specific clinical episodes that he must manage. The realism of the system is outstanding, and the debriefing greatly enhances CASE's value.
UF Anesthesia Simulator Developed by: Michael L. Good, M.D., Sem Lampotang, M.E., Gordon L. Gibby, M.D. and J.S. Gravenstein, M.D.; University of Florida, Gainesville, FL. "The UF Anesthesia Simulator is an actual anesthesia machine with real monitors that creates realistic critical incidents demanding real-life responses. Its instructional sequence has an excellent graphic model, a practical test, and immediate feedback. It has obvious applications to a wide audience now.
GAS MAN Developed by: James Philip, M.E. (E), M.D.; Brigham & Women's Hospital, Boston, MA: "One of the earliest simulations, only GAS MAN clearly teaches inhalation anesthesia induction to the beginner. Trainees learn this difficult concept using a handbook and computer aided instruction."
Application of the MGH Hemodynamic Waveform Database Developed by: Reid Rubsamen, M.D., James Welch, B.S., Richard Teplick, M.D., Penny Ford, R.N., M.S. and Ronald Newbower, Ph.D.; Massachusetts General Hospital, Boston, MA: "This project provides rapid access to representative samples of hemodynamic traces via an IBM compatible microcomputer. We appreciated the ability to display each set of tracings on a monitor of the dini6an's choice. It is applicable to training personnel in operating rooms, recovery rooms, critical care units and emergency rooms."
Anesthesia Simulator/Recorder (ASR) Developed by: Howard A. Schwid, M.D.; Veterans Administration Medical Center, Seattle, WA: "Dr. Schwid has created a very impressive physiologic and pharmacologic patient model simulating the interactions of the administration of 50 cardiovascular and anesthetic drugs. This simulation is an example of the power, value and versatility of computer models (IBM AT) used for anesthesia and critical care education."
An Anesthesia-Model-Driven Simulator Developed by: N. Ty Smith, M.D.; Veterans Administration Medical Center, San Diego, CA: "Dr. Smith has produced an elegant, highly sophisticated computer simulation of administering a general anesthetic one that allows, even demands, a high level of cognitive activity on the part of the operator. The screen is uncluttered and easy to read, the graphic display is similar to what we see in the OR, and the real-time nature of operator/computer interactions is a definite plus."
"Dr. Block" Developed by: Dwayne Westenskow, Ph.D., R.R. Jaklitsch, M.S. and A.A. Bruce, B.S.; University of Utah, Salt Lake City, UT: "This computer model simulates monitoring neuromuscular blockade and reversal, enabling the user to practice on a menu driven IBM AT instead of patients. The student determines drug doses, and the option of up to 20 x real time allows events to occur fast enough for the program to remain challenging. I think it would be popular among medical students and anesthesiology residents."
Anesthesia Work Station . Simulation of Machine Failures Using an Oil/Water Long Model Developed by: Dwayne Westenskow, Ph.D., Robert Loeb, M.D., Josef Brunner, Ph.D., Barry Feldman, M.S. and Nathan Pace, M.D.; University of Utah, Salt Lake City, UT. "The device is an evolving model of pulmonary mechanics, gas exchange, and distribution of inhalational agents to tissues. Its design is simple and elegant, and the experiments may be easily performed without using living models. It has significant educational potential."
The response to this workshop was so positive that a second one is being planned for September 22-24, 1989 in Rockville, Maryland, close to Washington, D.C. Anyone interested in attending, either as an exhibitor of a training device, as an educator, or as an interested clinician, should write to this author. The number of participants is limited; we will, therefore, reserve space on a first-come, first-serve basis.
J.S. Gravenstein, M.D., Department of Anesthesiology,
University of Florida, Gainesville, FL 32610-0254 is on
the APSF Executive Committee and chairs the Education and Training Committee.
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The Anesthesia Patient Safety Foundation Newsletter is the official publication of the nonprofit Anesthesia Patient Safety Foundation and is published quarterly in March, June, September, and December at Overland Park, Kansas. Annual membership: Individual $25.00, Corporate $500.00. This and any additional contributions to the Foundation are tax deductible @Copyright, Anesthesia Patient Safety Foundation, 1988.
The opinions expressed in this newsletter are not necessarily those of the Anesthesia Patient Safety Foundation or its members or board of directors. Validity of opinions presented, drug dosages, accuracy and completeness of content are not guaranteed by the APSF.
APSF Executive Committee: Ellison C. Pierce, Jr., M.D., President; W Dekle Rountree, Jr., Vice-President; E.S. Siker, M.D., Secretary; Burton A. Dole, Jr., Treasurer; Jeffrey & Cooper, Ph.D.; Joachim S. Gavenstein, M.D.; James E Holzer, J.D.
Newsletter Editorial Board: John H. Eichhorn, M.D., Stanley 1. Aukburg, M.D., Jeffrey M. Beutler, C.R.N.A., M.S., Ralph A. Epstein, M.D., David E. Lees, M.D., Bernard V. Wetchler, M.D., Mr. Mark D. Wood
Address all general, membership, and subscription tion correspondence to:
Administrator Anesthesia Patient Safety Foundation
515 Busse Highway
Park Ridge, IL 60068
Address Newsletter editorial comments, questions, letters, and suggestions to:
John H. Eichhorn, M.D. Editor, APSF Newsletter; Dept. Anesthesia
Beth Israel Hospital, DA-717 Boston, MA 02215
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