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A Brief History of the Patient Safety Movement in Anaesthesia

  • Chapter
The Wondrous Story of Anesthesia

Abstract

Approaches to safety began slowly. It took a century for ether to fully replace chloroform and for PIN indexing to be introduced for gas cylinders. In the 1960’s Holland in Australia and Harrison in South Africa initiated longitudinal anaesthesia mortality studies and showed a decline from 1:10,000 to 1:20,000 cases for fit patients. The relative safety of anaesthesia was confirmed by a large scale medical record review in 1990. In the 1980’s Cooper introduced incident monitoring and Cheney started the closed claim study. Dealing with the lessons from these was improved by the development of realistic simulation for teaching and pre-compiled responses for the management of crises. These advance underpinned the worldwide introduction of pulse oximetry, anaesthesia safety standards and check lists. Systematic improvement in drugs, equipment, techniques, infrastructure, training and the status of anaesthetists has underpinned the remarkable improvements in patient safety to date and further improvements in these areas will maintain the place of anaesthesia as a role model for patient safety.

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References

  1. Rushman G, Davies N, Atkinson R. A short history of anaesthesia. Oxford: Butterworth-Heinemann; 1996.

    Google Scholar 

  2. Sykes K. Personal Communication. “References to Anesthesia in 19th Centure British regional newspapers”. March 19 1847 Times, 2011.

    Google Scholar 

  3. Sykes K. Personal Communication. “References to Anesthesia in 19th Centure British regional newspapers”. February 3 1848 Times. 2011.

    Google Scholar 

  4. Knight PR 3rd, Bacon DR. An unexplained death: Hannah Greener and chloroform. Anesthesiology. 2002;96:1250–53.

    PubMed  Google Scholar 

  5. Sykes W. Essays on the first hundred years of anaesthesia. London: William Clowes (Beccles); 1982.

    Google Scholar 

  6. Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978;49:399–406.

    CAS  PubMed  Google Scholar 

  7. Gaba DM. Anaesthesiology as a model for patient safety in health care. BMJ. 2000;320:785–8.

    CAS  PubMed  Google Scholar 

  8. Utting JE, Gray TC, Shelley FC. Human misadventure in anaesthesia. Can Anaesth Soc J. 1979;26:472–8.

    CAS  PubMed  Google Scholar 

  9. Aders A, Aders H. Anaesthetic adverse incident reports: an Australian study of 1,231 outcomes. Anaesth Intens Care. 2005;33:336–44.

    CAS  Google Scholar 

  10. Lagasse RS. Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. Anesthesiology. 2002;97:1609–17.

    PubMed  Google Scholar 

  11. Dripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in surgical mortality. JAMA. 1961;178:261–6.

    CAS  PubMed  Google Scholar 

  12. Davies JM, Strunin L. Anesthesia in 1984: how safe is it? Can Med Assoc J. 1984;131:437–41.

    CAS  PubMed Central  PubMed  Google Scholar 

  13. Derrington MC, Smith G. A review of studies of anaesthetic risk, morbidity and mortality. Br J Anaesth. 1987;59:815–33.

    CAS  PubMed  Google Scholar 

  14. Sykes K. Anaesthesia and the times. History of Anaesthesia Society Proceedings 2008;39:15–19 (paper given in York June 27th, 2008).

    Google Scholar 

  15. Holland R. Special committee investigating deaths under anaesthesia. Report on 745 classified cases, 1960–1968. Med J Aust. 1970;1:573–94.

    Google Scholar 

  16. Holland R. Anaesthetic mortality in New South Wales. Br J Anaesth. 1987;59:834–41.

    CAS  PubMed  Google Scholar 

  17. Warden JC, Borton CL, Horan BF. Mortality associated with anaesthesia in New South Wales, 1984–1990. Med J Aust. 1994;161:585–93.

    CAS  PubMed  Google Scholar 

  18. Gibbs N, Rodoreda P. Anaesthetic mortality rates in Western Australia 1980–2002. Anaesth Intens Care. 2005;33:616–22.

    CAS  Google Scholar 

  19. Gibbs N, Borton C. A review of anaesthesia related mortality 2000 to 2002. Melbourne: Australian and New Zealand College of Anaesthetists; 2006.

    Google Scholar 

  20. Gibbs NM. Milestones in anaesthesia-related mortality and morbidity reporting in Australia. Anaesth Intens Care. 2010;38:807–8.

    CAS  Google Scholar 

  21. Harrison GG. Anaesthetic contributory death’its incidence and causes. I. Incidence. S Afr Med J. 1968;42:514–8.

    CAS  PubMed  Google Scholar 

  22. Harrison GG. Death attributable to anaesthesia. A 10-year survey (1967–1976). Br J Anaesth. 1978;50:1041–6.

    CAS  PubMed  Google Scholar 

  23. Harrison GG. Death due to anaesthesia at Groote Schuur Hospital, Cape Town’1956–1987. Part I. Incidence. S Afr Med J. 1990;77:412–5.

    CAS  PubMed  Google Scholar 

  24. Institute of Medicine. To err is human: building a safer health system. Washington DC: National Academies Press; 1999.

    Google Scholar 

  25. Arbous MS, Meursing AE, van Kleef JW, de Lange JJ, Spoormans HH, Touw P, Werner FM, Grobbee DE. Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology. 2005;102:257–68.

    PubMed  Google Scholar 

  26. Hogan H, Healey F, Neale G, Thomson R, Vincent C, Black N. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf. 2012;21:737–45.

    PubMed Central  PubMed  Google Scholar 

  27. Runciman WB. Iatrogenic harm and anaesthesia in Australia. Anaesth Intens Care. 2005;33:297–300.

    CAS  Google Scholar 

  28. Greenland KB, Acott C, Segal R, Riley RH, Merry AF. Delayed airway compromise following extubation of adult patients who required surgical drainage of Ludwig’s angina: comment on three coronial cases. Anaesth Intens Care. 2011;39:506–8.

    CAS  Google Scholar 

  29. Enright A, Merry A. The WFSA and patient safety in the perioperative setting. Can J Anaesth. 2009;56:8–13.

    PubMed  Google Scholar 

  30. Ouro-Bang’na Maman AF, Tomta K, Ahouangbevi S, Chobli M. Deaths associated with anaesthesia in Togo, West Africa. Trop Doct. 2005;35:220–2.

    PubMed  Google Scholar 

  31. WHO Safe Surgery Saves Lives.http://www.who.int/patientsafety/safesurgery/en/. Accessed 17 March 2010.

  32. Walker IA, Merry AF, Wilson IH, McHugh GA, O’Sullivan E, Thoms GM, Nuevo F, Whitaker DK, teams GOP. Global oximetry: an international anaesthesia quality improvement project. Anaesthesia. 2009;64:1051–60.

    CAS  PubMed  Google Scholar 

  33. Beecher HK, Todd DP. A study of the deaths associated with anesthesia and surgery. Ann Surg. 1954;140:2–34.

    CAS  PubMed  Google Scholar 

  34. Abajian J, Arrowood JG, Barrett RH, Dwyer CS, Eversole UH, Fine JH, Hand LV, Howrie WC, Marcus PS, Martin SJ, Nicholson MJ, Saklad E, Saklad M, Sellman P, Smith RM, Woodbridge PD. Critique of “A Study of the Deaths Associated with Anesthesia and Surgery”. Ann Surg. 1955;142:138–41.

    CAS  PubMed  Google Scholar 

  35. Harrison GG. Control of the malignant hyperpyrexic syndrome in MHS swine by dantrolene sodium. Br J Anaesth. 1975;47:62–5.

    CAS  PubMed  Google Scholar 

  36. Dorsch JA, Dorsch SE, Series Editor Gravlee GP. A practical approach to anesthesia equipment. Wolters Kluwer’Lippincott Williams and Wilkins, Philadelphia.; 2011.

    Google Scholar 

  37. Russell WJ. Equipment for anaesthesia and intensive care. Adelaide: W J Russell; 1997.

    Google Scholar 

  38. Macintosh RR. Deaths under anaesthetics. Br J Anaesth. 1949;21:107–36.

    CAS  PubMed  Google Scholar 

  39. International Taskforce on Anaesthesia Safety. International standards for a safe practice of anaesthesia. Eur J Anaesthesiol. 1993;10 (Suppl 7):12–15; updated:http://anaesthesiologists.org/en/safety/2008-international-standards-for-a-safe-practice-of-anaesthesia.html. Accessed 17 March 10).

  40. Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth. 2010;57:1027–34.

    PubMed Central  PubMed  Google Scholar 

  41. Keats AS. What do we know about anesthetic mortality? Anesthesiology. 1979;50:387–92.

    CAS  PubMed  Google Scholar 

  42. Hamilton WK. Unexpected deaths during anesthesia: wherein lies the cause? Anesthesiology. 1979;50:381–3.

    CAS  PubMed  Google Scholar 

  43. Todd RH. On some points connected with the accidents of anaesthesia and their treatment. The Australasian Medical Gazette. 1889;9:38–42.

    Google Scholar 

  44. Gaba DM, Maxwell M, DeAnda A. Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology. 1987;66:670–76.

    CAS  PubMed  Google Scholar 

  45. Cooper JB, Gaba DM. A strategy for preventing anesthesia accidents. Int Anesthesiol Clin. 1989;27:148–52.

    CAS  PubMed  Google Scholar 

  46. Merry AF, McCall Smith A. Errors, Medicine and the Law. Cambridge: Cambridge University Press; 2001.

    Google Scholar 

  47. Holzer JF. Liability insurance issues in anesthesiology. Int Anesthesiol Clin. 1989;27:205–12.

    CAS  PubMed  Google Scholar 

  48. Pierce EC Jr. The 34th Rovenstine Lecture. 40 years behind the mask: safety revisited. Anesthesiology. 1996;84:965–75.

    PubMed  Google Scholar 

  49. Cooper J. Patient safety and biomedical engineering. In: Kitz R, editor. This is No Humbug: reminiscences of the Department of Anesthesia at the Massachusetts General Hospital. Boston: Department of Anesthesia and Critical Care, Massachusetts General Hospital; 2002. S. 377–420.

    Google Scholar 

  50. Eichhorn J. The APSF at 25: pioneering success in safety but challenges remain. APSF Newsletter 2010;25:1, 23–4, 35–9.

    Google Scholar 

  51. Solazzi RW, Ward RJ. Analysis of anesthetic mishaps. The spectrum of medical liability cases. Int Anesthesiol Clin. 1984;22:43–59.

    CAS  PubMed  Google Scholar 

  52. Keats AS. The Closed Claims Study. Anesthesiology. 1990;73:199–201.

    CAS  PubMed  Google Scholar 

  53. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology. 1990;72:828–33.

    CAS  PubMed  Google Scholar 

  54. Posner KL, Caplan RA, Cheney FW. Variation in expert opinion in medical malpractice review. Anesthesiology. 1996;85:1049–54.

    CAS  PubMed  Google Scholar 

  55. Lunn JN, Devlin HB. Lessons from the confidential enquiry into perioperative deaths in three NHS regions. Lancet. 1987;2:1384–6.

    CAS  PubMed  Google Scholar 

  56. Lunn JN. The history and achievements of the National Confidential Enquiry into Perioperative Deaths. J Qual Clin Pract. 1998;18:29–35.

    CAS  PubMed  Google Scholar 

  57. Anaesthesia and Intensive Care Symposium’The Australian Incident Monitoring Study. Anaes Int Care. 1993;21.

    Google Scholar 

  58. Holland R, Hains J, Roberts JG, Runciman WB. Symposium’The Australian Incident Monitoring Study. Anaesth Intens Care. 1993;21:501–5.

    CAS  Google Scholar 

  59. Webb RK, van der Walt JH, Runciman WB, Williamson JA, Cockings J, Russell WJ, Helps S. The Australian Incident Monitoring Study. Which monitor? An analysis of 2000 incident reports. Anaesth Intens Care. 1993;21:529–42.

    CAS  Google Scholar 

  60. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Incidence of adverse events and negligence 2 hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370–6.

    CAS  PubMed  Google Scholar 

  61. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust. 1995;163:458–71.

    CAS  PubMed  Google Scholar 

  62. Runciman WB, Webb RK, Helps SC, Thomas EJ, Sexton EJ, Studdert DM, Brennan TA. A comparison of iatrogenic injury studies in Australia and the USA. II: reviewer behaviour and quality of care. Int J Qual Health Care. 2000;12:379–88.

    CAS  PubMed  Google Scholar 

  63. Runciman WB, Williamson JA, Deakin A, Benveniste KA, Bannon K, Hibbert PD. An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification. Qual Saf Health Care. 2006;15 (Suppl 1):i82–90.

    PubMed  Google Scholar 

  64. Sherman H, Castro G, Fletcher M, Hatlie M, Hibbert P, Jakob R, Koss R, Lewalle P, Loeb J, Perneger T, Runciman W, Thomson R, Van Der Schaaf T, Virtanen M. Towards an International Classification for Patient Safety: the conceptual framework. Int J Qual Health Care. 2009;21:2–8.

    PubMed  Google Scholar 

  65. Cooper JB, Gaba DM, Liang B, Woods D, Blum LN. The National Patient Safety Foundation agenda for research and development in patient safety. MedGenMed. 2000;2:E38.

    CAS  PubMed  Google Scholar 

  66. Merry AF, Webster CS, Hannam J, Mitchell SJ, Henderson R, Reid P, Edwards K-E, Jardim A, Pak N, Cooper J, Hopley L, Frampton C, Short TG. Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. BMJ. 2011;343:d5543.

    PubMed Central  PubMed  Google Scholar 

  67. Meyer JA, Rendell-Baker L. Safety and performance of anesthesia and ventilatory equipment. Anesthesiology. 1970;32:473–4.

    CAS  PubMed  Google Scholar 

  68. Rendell-Baker L. Some gas machine hazards and their elimination. Anesth Analg. 1976;55:26–33.

    CAS  PubMed  Google Scholar 

  69. Pierce EC Jr. Analysis of anesthetic mishaps. Historical perspectives. Int Anesthesiol Clin. 1984;22:1–16.

    PubMed  Google Scholar 

  70. Reason J. Human error. New York: Cambridge University Press; 1990.

    Google Scholar 

  71. Rendell-Baker L. Desirable performance characteristics of anesthetic machines. Int Anesthesiol Clin. 1974;12:1–24.

    CAS  PubMed  Google Scholar 

  72. Rendell-Baker L. Standards for anesthetic and ventilatory equipment. Int. Anesthesiol Clin. 1982;20:171–203.

    CAS  Google Scholar 

  73. Ritchie JR. Letter: a simple and reliable warning device for failing oxygen pressure. Br J Anaesth. 1974;46:323.

    CAS  PubMed  Google Scholar 

  74. Severinghaus JW, Honda Y. History of blood gas analysis. VII. Pulse oximetry. J Clin Monit. 1987;3:135–8.

    CAS  PubMed  Google Scholar 

  75. Westhorpe RN, Ball C. The pulse oximeter. Anaesth Intens Care. 2008;36:767.

    CAS  Google Scholar 

  76. Westhorpe RN, Ball C. The history of capnography. Anaesth Intens Care. 2010;38:611.

    CAS  Google Scholar 

  77. Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA. 1986;256:1017–20.

    CAS  PubMed  Google Scholar 

  78. Gaba D, Fish K, Howard S. Crisis management in anesthesiology. 1st ed. New York: Churchill Livingston; 1994.

    Google Scholar 

  79. Weller J, Morris R, Watterson L, Garden A, Flanagan B, Robinson B, Thompson W, Jones R. Effective management of anaesthetic crises: development and evaluation of a college-accredited simulation-based course for anaesthesia education in Australia and New Zealand. Simul Healthcar. 2006;1:209–14.

    Google Scholar 

  80. Tenner EW. Why things bite back’technology and the revenge of unintended consequences. New York: Vintage Books; 1997.

    Google Scholar 

  81. Treasure T. Lessons from the Bristol case. Br Med J. 1998;316:1685–86.

    CAS  Google Scholar 

  82. Smith R. All changed, changed utterly. British medicine will be transformed by the Bristol case. BMJ. 1998;316:1917–8.

    CAS  PubMed  Google Scholar 

  83. Kennedy I. Learning from Bristol: The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995: CM 5207 (London: The Stationery Office). Available at:http://www.bristol-inquiry.org.uk/. Accessed 29 May 2006, 2001.

  84. Reason J. Human error: models and management. Br Med J. 2000;320:768–70.

    CAS  Google Scholar 

  85. Gaba DM, Maxwell M, DeAnda A. Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology. 1987;66:670–6.

    CAS  PubMed  Google Scholar 

  86. Denson JS, Abrahamson S. A computer-controlled patient simulator. JAMA. 1969;208:504–08.

    CAS  PubMed  Google Scholar 

  87. Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: re-creating the operating room for research and training. Anesthesiology. 1988;69:387–94.

    CAS  PubMed  Google Scholar 

  88. Schwid HA. A flight simulator for general anesthesia training. Comput Biomed Res. 1987;20:64–75.

    CAS  PubMed  Google Scholar 

  89. Good ML, Gravenstein JS. Anesthesia simulators and training devices. Int Anesthesiol Clin. 1989;27:161–68.

    CAS  PubMed  Google Scholar 

  90. Carter DF. Man-made man: anesthesiological medical human simulator. J Assoc Adv Med Instrum. 1969;3:80–6.

    CAS  PubMed  Google Scholar 

  91. Cooper JB, Taqueti VR. A brief history of the development of mannequin simulators for clinical education and training. Qual Saf Health Care. 2004;13 (Suppl 1):i11–8.

    PubMed  Google Scholar 

  92. Merry AF, Peck DJ. Anaesthetists, errors in drug administration and the law. N Z Med J. 1995;108:185–7.

    CAS  PubMed  Google Scholar 

  93. Dyer C. Doctors suspended after injecting wrong drug into spine. Br Med J. 2001;322:257.

    CAS  Google Scholar 

  94. Orser BA, Byrick R. Anesthesia-related medication error: time to take action. Can J Anaesth. 2004;51:756–60.

    PubMed  Google Scholar 

  95. Merry AF, Webster CS. Medication error in New Zealand’time to act. N Z Med J. 2008;121:6–9.

    PubMed  Google Scholar 

  96. Eichhorn J. APSF hosts medication safety conference: consensus group defines challenges and opportunities for improved practice. APSF Newsletter. 2010;25:1–7.

    Google Scholar 

  97. Merry AF, Webster CS, Mathew DJ. A new, safety-oriented, integrated drug administration and automated anesthesia record system. Anesth Analg. 2001;93:385–90.

    CAS  PubMed  Google Scholar 

  98. Webster CS, Larsson L, Frampton CM, Weller J, McKenzie A, Cumin D, Merry AF. Clinical assessment of a new anaesthetic drug administration system: a prospective, controlled, longitudinal incident monitoring study. Anaesthesia. 2010;65:490–9.

    CAS  PubMed  Google Scholar 

  99. Jensen LS, Merry AF, Webster CS, Weller J, Larsson L. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia. 2004;59:493–504.

    CAS  PubMed  Google Scholar 

  100. Bacon DR, Ament R. Ralph Waters and the beginnings of academic anesthesiology in the United States: the Wisconsin Template. J Clin Anesth. 1995;7:534–43.

    CAS  PubMed  Google Scholar 

  101. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA, Safe SSavesLStudyG. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–9.

    CAS  PubMed  Google Scholar 

  102. de Vries EN, Prins HA, Crolla RMPH, den Outer AJ, van Andel G, van Helden SH, Schlack WS, van Putten MA, Gouma DJ, Dijkgraaf MGW, Smorenburg SM, Boermeester MA, Group SC. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363:1928–37.

    PubMed  Google Scholar 

  103. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304:1693–700.

    CAS  PubMed  Google Scholar 

  104. Birkmeyer JD. Strategies for improving surgical quality’checklists and beyond. N Engl J Med. 2010;363:1963–5.

    CAS  PubMed  Google Scholar 

  105. The KK 2008 TIME 100. Time Magazine: Time Warner, 2009.

    Google Scholar 

  106. Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit.[see comment]. Crit Care Med. 2004;32:2014–20.

    PubMed  Google Scholar 

  107. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–32.

    CAS  PubMed  Google Scholar 

  108. Walker IA, Wilson IH. Anaesthesia in developing countries-a risk for patients. Lancet. 2008;371:968–9.

    PubMed  Google Scholar 

  109. Gawande A. Complications. New York: Henry Holt and Company; 2002.

    Google Scholar 

  110. Gawande A. Better. New York: Henry Holt and Company; 2007.

    Google Scholar 

  111. Gawande A. The checklist manifesto. New York: Metropolitan Books Henry Holt and Company; 2010.

    Google Scholar 

  112. Funk LM, Weiser TG, Berry WR, Lipsitz SR, Merry AF, Enright AC, Wilson IH, Dziekan G, Gawande AA. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet. 2010;376:1055–61.

    PubMed  Google Scholar 

  113. Lifebox.

    Google Scholar 

  114. Merry AF, Eichhorn JH, Wilson IH. Extending the WHO ‘Safe Surgery Saves Lives’ project through Global Oximetry. Anaesthesia. 2009;64:1045–8.

    CAS  PubMed  Google Scholar 

  115. Runciman WB, Baker GR, Michel P, Jauregui IL, Lilford RJ, Andermann A, Flin R, Weeks WB. The epistemology of patient safety research. Int J Evid Based Healthc. 2008;6:476–86.

    PubMed  Google Scholar 

  116. Runciman B, Merry A, Walton M. Safety and ethics in healthcare: A guide to getting it right. Aldershot: Ashgate; 2007.

    Google Scholar 

  117. Donabedian A. The quality of care: how can it be assessed? JAMA. 1988;260:1743–48.

    CAS  PubMed  Google Scholar 

  118. Donabedian A. An Introduction to quality assurance in health care. New York:Oxford University Press; 2003.

    Google Scholar 

  119. WHO Guidelines for Safe Surgery. Safe surgery saves lives. Geneva: WHO Press: World Health Organization, 2009.

    Google Scholar 

  120. Weiser TG, Makary MA, Haynes AB, Dziekan G, Berry WR, Gawande AA, Safe SSavesLM, Study GiM A. Standardised metrics for global surgical surveillance. Lancet. 2009;374:1113–7.

    PubMed  Google Scholar 

  121. Eichhorn JH. Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology. 1989;70:572–7.

    CAS  PubMed  Google Scholar 

  122. Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesth Intens Care. 2001;29:494–500.

    CAS  Google Scholar 

  123. Shekelle PG, Pronovost PJ, Wachter RM, Taylor SL, Dy SM, Foy R, Hempel S, McDonald KM, Ovretveit J, Rubenstein LV, Adams AS, Angood PB, Bates DW, Bickman L, Carayon P, Donaldson L, Duan N, Farley DO, Greenhalgh T, Haughom J, Lake ET, Lilford R, Lohr KN, Meyer GS, Miller MR, Neuhauser DV, Ryan G, Saint S, Shojania KG, Shortell SM, Stevens DP, Walshe K. Advancing the science of patient safety. Ann Intern Med. 2011;154:693–6.

    PubMed  Google Scholar 

  124. Pronovost PJ, Lilford R. Analysis & commentary: a road map for improving the performance of performance measures. Health Aff (Millwood). 2011;30:569–73.

    Google Scholar 

  125. Pronovost PJ, Cardo DM, Goeschel CA, Berenholtz SM, Saint S, Jernigan JA. A research framework for reducing preventable patient harm. Clin Infect Dis. 2011;52:507–13.

    PubMed  Google Scholar 

  126. Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA. 2002;288:501–7.

    PubMed  Google Scholar 

  127. Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. Br Med J. 2003;327:1459–61.

    Google Scholar 

  128. Merry AF, Davies JM, Maltby JR. Qualitative research in health care. Br J Anaesth. 2000;84:552–55.

    CAS  PubMed  Google Scholar 

  129. Moller JT, Pedersen T, Rasmussen LS, Jensen PF, Pedersen BD, Ravlo O, Rasmussen NH, Espersen K, Johannessen NW, Cooper JB, Gravestein JS, Chraemmer-Jorgensen B, Wiberg-Jorgensen F, Djernes M, Heslet L, Johansen SH. Randomized evaluation of pulse oximetry in 20,802 patients: I. Design, demography, pulse oximetry failure rate, and overall complication rate. Anesthesiology. 1993;78:436–44.

    CAS  PubMed  Google Scholar 

  130. Moller JT, Johannessen NW, Espersen K, Ravlo O, Pedersen BD, Jensen PF, Rasmussen NH, Rasmussen LS, Pedersen T, Cooper JB. Randomized evaluation of pulse oximetry in 20,802 patients: II. Perioperative events and postoperative complications. Anesthesiology. 1993;78:445–53.

    CAS  PubMed  Google Scholar 

  131. Savel RH, Goldstein EB, Gropper MA. Critical care checklists, the Keystone Project, and the Office for Human Research Protections: a case for streamlining the approval process in quality-improvement research.[see comment]. Crit Care Med. 2009;37:725–8.

    PubMed  Google Scholar 

  132. McGlynn E, Asch S, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr E. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635–45.

    PubMed  Google Scholar 

  133. Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, Day RO, Hindmarsh DM, McGlynn EA, Braithwaite J. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust. 2012;197:100–5.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. School of Psychology, Social Work and Social Policy, Sleep Research Centre, University of South Australia City East Campus, North Terrace, Adelaide, SA, Australia

    William B. Runciman B.Sc (Med), MBBCh, FANZCA, FJFICM, FHKCA, FRCA, PhD

  2. Department of Anaesthesiology, University of Auckland, Auckland, New Zealand

    Alan F. Merry MBChB, FANZCA, FFPMANZCA, FRCA

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  1. William B. Runciman B.Sc (Med), MBBCh, FANZCA, FJFICM, FHKCA, FRCA, PhD
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  2. Alan F. Merry MBChB, FANZCA, FFPMANZCA, FRCA
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Correspondence to William B. Runciman B.Sc (Med), MBBCh, FANZCA, FJFICM, FHKCA, FRCA, PhD .

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Editors and Affiliations

  1. Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA

    Edmond I Eger II MD Emeritus Professor

  2. Departments of Anesthesia, Stanford University, Stanford, CA, USA

    Lawrence J. Saidman MD Emeritus Professor

  3. Geoffrey Kaye Museum of Anaesthetic History, Australian and New Zealand College of Anaesthetists, Melbourne, VIC, Australia

    Rod N. Westhorpe OAM, MB, BS FRCA, FANZCA Former Honorary Curator

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© 2014 Edmond I Eger, MD

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Runciman, W., Merry, A. (2014). A Brief History of the Patient Safety Movement in Anaesthesia. In: Eger II, E., Saidman, L., Westhorpe, R. (eds) The Wondrous Story of Anesthesia. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-8441-7_41

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  • DOI: https://doi.org/10.1007/978-1-4614-8441-7_41

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4614-8440-0

  • Online ISBN: 978-1-4614-8441-7

  • eBook Packages: MedicineMedicine (R0)

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