The Lewis H. Wright Memorial Lecture at the ASA — The APSF and anesthesia patient safety: Leadership lessons from the legacy of Jeep Pierce

Dr. Jeffrey B. Cooper delivers the Lewis H. Wright Memorial Lecture at the ASA

This year`s lecture was delivered by one of the founding members of the Anesthesiology Patient Safety Foundation (APSF), Dr. Jeffrey B. Cooper. Dr. Cooper has been a central figure in patient safety and anesthesiology since his early days as a biomedical engineer in the Department of Anesthesiology at Massachusetts General Hospital. His talk chronicled the creation of the APSF and the leadership and vision of its founders. He said from the outset that one of the objectives of his lecture was to have us all feel very good about the role of the anesthesiology community and patient safety.

Five elements came together in a short time frame to create the APSF. In the 1980s anesthesiology malpractice insurance was very high, reflecting the danger inherent in routine care. A television show, 20/20, aired a program in 1982 highlighting the dangers of “The Deep Sleep.” Viewers learned that every year, 6000 patients could be harmed by complications related to anesthesiology care, ultimately leading to death and brain injury. It was at this juncture that Dr. Ellison “Jeep” Pierce, ASA president at the time, felt that action was necessary to investigate the causes of mishaps and to ensure anesthesiology safety. He called together a diverse group of experts who could do just that, and the result was that the APSF was founded. The statement “That no patient shall be harmed by the effects of anesthesiology” is the mission statement of the APSF.

Dr. Cooper`s early research on equipment errors using the Critical Incident Technique demonstrated that although some equipment did merit improvement, it was often the interface with the user or a systems problem that led to anesthesia error. The APSF has always had a diverse (as well as volunteer) membership including leaders in anesthesiology, engineering, device manufacturing and also nursing. Through workshops and articles in the newsletter, the APSF tackles a steady stream of practical projects.

Focused research and improvements over 26 years have made anesthesiology very safe, but Dr. Cooper noted that some improvements are still needed. The anesthesiology community needs to address complexity and change before it happens. We need to train with allied health professionals and learn teamwork skills. Checklists are important tools and act as a forum for better communication between healthcare workers. There is still work to be done in decision support, handoffs, vision loss, OR fires and medication errors, just to name a few areas of possible improvement. One thing is certainly true after hearing Dr. Cooper`s lecture: we do feel good about patient safety and we also appreciate his role and that of Jeep Pierce in the founding of the APSF in order to steer patient safety in our specialty.