Anaesthesiology as a model for patient safety in health care
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7237.785 (Published 18 March 2000) Cite this as: BMJ 2000;320:785
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The concept of "black boxes" in anesthesiology has been discussed in
the professions several times in the past. The Anesthesia Patient Safety
Foundation (U.S.) has been discussing this concept informally, and may
convene more formal meetings on the feasibility of this approach.
However, there are obstacles. Privacy issues are important and have
played a major role in the way that black boxes are used in aviation.
Only the final 30 minutes of cockpit voice data are recorded, and the
cockpit voice recorder is only downloaded if there is an accident. Flight
data recorder data is also carefully guarded and there are strict
limitations on how it can be used.
A problem in anesthesiology is that we often do not know for sure
when an adverse event has occurred until we see how things play out for
hours or days. Also, the number of events that are not "perfect" is very
high. These cannot all be investigated in the way that the NTSB
investigates aircraft accidents in the U.S.
None of these (or the other relevant problems) are insurmountable,
but they ARE difficult problems. Thus, it will not be easy to put into
practice an analog to the aviation system of "black boxes" but I agree
that serious thought should be given to the issue to define the problems
and potential solutions to them.
Competing interests: No competing interests
Editor- I found the BMJ issue (18 March 2000) on 'reducing error and
improving safety' very appealing as a trainee in Anaesthesia.
I am interested to know if there have been attempts to device a system
similar to 'Black Box' in Anaesthesia. We know that the entire concept of
critical incident and cockpit drill has been very appropriately imported
from the field of Aviation. Black box concept in Anaesthetic practice that
can keep the record of patients' parameters and Anaesthetists' activities
would prove very helpful.
I understand the limitations of such an automated record keeping system
such as a failure of a pulse oxymetre to pick up a signal can record the
data which is incompatible with patient's clinical condition. But I am
sure, even in the field of aviation, there must be situations similar to
this and the ways to overcome such difficulties. Keeping this in mind, is
it possible to device the monitors (black box) which can detect variations
in the parameters from the recognized 'out of limits' range.
Vinay Ratnalikar
specialist registrar
Department of Anaesthetics,
Singleton Hospital,
Swansea NHS Trust, Swansea.
getvin@hotmail.com
1.Gaba D M. Anaesthesiology as a model for patient safety in health
care. BMJ 2000;320:785-8(18 March.)
Competing interests: No competing interests
Differences between anaesthesia and anesthesiology
EDITOR - We agree with Dr. Gaba (BMJ 2000:320:783-8) that anaesthesia
has embraced the issues of patient safety, indeed the changes he describes
have occurred in the United Kingdom. However there are significant
differences (other than spelling) between anaesthesia in the United
Kingdom and anesthesiology in the United States.
In the United Kingdom all anaesthetics are given by medically qualified
anaesthetists who are the single largest medical specialty. Not only do
anaesthetists fulfil their traditional roles in the operating theatres and
extra theatre commitments such as obstetric and imaging units, but they
are also heavily involved in trauma and resuscitation services and
intensive care medicine (93% of sessions in intensive care medicine are
done by anaesthetists). This is in contrast to the United States where
there are a substantial number of nurse anesthetists as well as medically
qualified anesthesiologists and their involvement in intensive care
medicine is often limited.
The imperative for the change in attitude to safety in the United States
was severe medico - legal pressures. Although there are such pressures in
the United Kingdom our indemnity arrangements are not the same as the
United States and would not of themselves led to change. Nevertheless,
patient safety is a high priority for anaesthetists in the United Kingdom.
We believe this is due to the roles of the Royal College of Anaesthetists
and the Association of Anaesthetists of Great Britain and Ireland through
whom patient safety issues have long been brought to the attention of all
anaesthetists and all the hospitals where they work. For example, the
College has statutory powers in relation to training and has a
comprehensive visiting scheme which reviews and approves the ability of
consultants and their hospitals to provide an environment which meets the
College's published training programme which includes safety issues. The
Association, which has its own Safety Committee, publishes guidelines on a
regular basis and these include safety related documents such as minimum
monitoring standards, the anaesthesia team and organization of anaesthetic
departments. Both bodies are consulted by the Department of Health on all
matters relating to anaesthesia.
In 1998 Good Practice: A Guide for Departments of Anaesthesia, published
jointly between the College and the Association, was launched at a unique
meeting attended by representatives from all anaesthetic departments in
the United Kingdom. This was followed by the formation of a Joint Good
Practice Committee between the two bodies which has developed a personal
portfolio for anaesthetists, a portfolio for anaesthetic departments and
guidance on appraisal and assessment ready for implementing clinical
governance and revalidation. These documents may be found on both the
College website www.rcoa.ac.uk and the Association website www.aagbi.org.
In addition the Joint Committee provides a 'rapid response' team to advise
trusts and departments over any issue concerning anaesthesia, including
patient safety, that cannot be resolved locally.
The United States does not have a National Health Service or national
organisations with the power and influence of the College and the
Association. Therefore the solution for promoting patient safety in the
United States was to set up the Anesthesia Safety Foundation. However, the
Foundation is a voluntary body and does not have access to all parts of
health care in the United States as the College and the Association do
here in the United Kingdom.
Anaesthesia in the United Kingdom as in the United States appears safer
than ever. Nevertheless, things still go wrong and may cause significant
patient harm. However, we do not think we need a separate 'Patient Safety
Foundation' in the United Kingdom. Although it is currently fashionable to
decry organisations such as Colleges and Associations in the rush to
'modernisation', our track record needs no defence, we have committed
leadership and an excellent framework for the future. However, we are not
complacent and agree that 'the price of patient safety is eternal
vigilance'.
Leo Strunin
President
Royal College of Anaesthetists,
48-49 Russell Square,
London WC1B 4JY
Maldwyn Morgan
President
Paul Cartwright
Chairman
Standards Committee
Association of Anaesthetists of Great Britain and Ireland,
9 Bedford Square,
London WC1B 3RA
Competing interests: No competing interests