Opportunities to enhance perioperative patient safety: 2013 and beyond

Donald R. Miller 0 0 D. R. Miller, MD (&) Department of Anesthesia , The Ottawa Hospital and University of Ottawa , General Campus CCW 1401, 501 Smyth Road, Ottawa , ON K1H 8L6, Canada We are pleased to dedicate this special theme issue of the Journal to the important topic of perioperative patient safety. Anesthesiologists take justifiable pride in the development and implementation of robust patient safety initiatives throughout the world. At the same time, many of us are challenged daily in caring for patients with everincreasing medical complexity. We provide anesthesia for routine and complex surgical and interventional procedures in the operating room and ''remote settings'' within the context of an ever-complex working environment. In considering these contemporary and patient-focused challenges, some months ago, our editorial team invited experts from Canada and internationally to address current key issues in perioperative patient safety in a series of brief review articles. I acknowledge with special thanks our Board Member, Dr. Alan F. Merry, for his thoughtful input and contribution to this issue, and for his instrumental role as co-editor and editorialist.1 According to Journal policy, these articles have all been externally reviewed and edited, and for the benefit of our readers, we have harmonized the outline of each article to include a structured abstract, a list of key words, and two or three multiple choice questions to guide readers' attention to the key points. In the first review article, Dr. John H. Eichhorn provides an overview of practical current issues in perioperative patient safety. He emphasizes the fact that important gains in patient safety over the past three decades have been attributed largely to the development of behaviours known as ''safety monitoring''.2 Extension of the human senses - through electronic monitors, such as capnography and pulse oximetry, has been a major advance, but Dr. Eichhorn cautions that, in the highly developed world, this current success is threatened by complacency and production pressure which bring forth new challenges. Electronic medical records, hence, anesthesia information management systems (AIMS), provide enormous potential to enhance patient safety. Anesthesiologists have the opportunity to become key leaders in the adoption, implementation, and integration of AIMS and healthsystem information technology (IT) solutions in general. In their review article on the evolving role of IT in perioperative patient safety, Drs. Michael Stabile and Lebron Cooper identify that uptake of health IT and AIMS remains variable despite the potential benefits, and they identify advantages and barriers to the adoption and implementation of IT in general and AIMS in particular.3 Later articles in this theme issue address specific clinical issues that present ongoing challenges to the practicing clinician. Medication error remains a leading cause of adverse events in the perioperative setting. In their article Improving drug safety for patients undergoing anesthesia and surgery, Drs. Beverley A. Orser, Sylvia Hyland, C. Ruth Wilson, David U, and Ian Sheppard summarize recent advances, tools and interventions designed to improve drug safety, relevant to the practicing anesthesiologist.4 Important Canadian and international initiatives such as new standards for labelling of drug ampoules and vials, and the development of bar code systems that provide as systematic approach to double checking or drug verification in the operating room, are reviewed. This article also addresses the important subject of medication reconciliation as a means to enhance patient safety. There is now fairly compelling evidence that implementation of checklists into clinical practice can enhance patient safety. In their review article on perioperative checklist methodologies, Dr. Thomas G. Weiser and William R. Berry consider some of the mechanisms by which checklists work and evaluate evidence supporting their use.5 Another important topic in this theme issue is the role of practice guidelines and evidence-based medicine in perioperative patient safety. In his review article, Dr. Edward Crosby discusses the impact of clinical practice guidelines on outcomes of care and patient safety. Under certain conditions, guidelines can add value to care and improve outcomes; they need to be evidence-based, methodologically sound, and appropriately applied to patients and clinical scenarios. Simply summarizing evidence in a guideline is an inadequate process. To achieve the benefit of guidelines, implementation strategies need to be robust.6 We invited Dr. Angela Enright, former President of the World Federation of Societies of Anaesthesiologists (WFSA), to provide an update on safety aspects of anesthesia in under-resourced locations. Dr. Enright identifies that an unresolved shortage of trained anesthesia providers (both physician and non-physician alike), especially outside urban areas, is an important contributing factor to high rates of morbidity and mortality in some developing countries.7 There is also a well-recognized shortage of equipment and related resources for anesthesia. Lifebox is one example of a charitable foundation dedicated to supplying pulse oximeters to low- and middle-income countries. The recent adoption of the World Health Organizations Surgical Safety Checklist is a low-cost initiative that can further reduce morbidity and mortality. Drs. Jilles B. Bijker and Adrian W. Gelb examine the role of hypotension in perioperative stroke. Although hypoperfusion is often identified as a possible cause of postoperative stroke, these experts indicate that the role of intraoperative hypotension in the occurrence and development of postoperative cerebral ischemia has never been the subject of thorough investigation.8 In this review article, the authors provide an overview of the available literature on the subject, and they identify challenges to help resolve the problem of perioperative cerebral ischemia. Drs. Gregory Hare, John Freedman, and C. David Mazer examine other important patient safety issues posed by the risks of anemia and related transfusion strategies in the perioperative setting. Impairment of tissue oxygen delivery likely contributes as a central mechanism to anemiainduced organ injury; however, the existing treatments for anemia (i.e., transfusion, erythropoiesis stimulating agents, blood substitutes) have not produced a demonstrable improvement in patient outcomes despite their efficacy to increase blood oxygen content.9 The authors review and examine new strategies to avoid both anemia and transfusion with the goal to improve patient outcomes and safety. Another practical and topical issue is the anesthesiologists role in the prevention of surgical site infections (SSIs). Herein, Drs. Shawn S. Forbes and Richard F. McLean consider the important role of anesthesiologists as champions in the multidisciplinary effor (...truncated)