To the Editor We thank the authors of the article titled, "The Origins, Evolution, and Spread of Anesthesia Monitoring Standards: From Boston to Around the World," for their excellent summary of our work in developing the first standards of care in the specialty of anesthesiology.1 We wish to clarify and expand on a few points. In 1984, the chiefs of Harvard Medical School's anesthesia departments asked us to "study" the problem of disproportionately high payouts relative to anesthesia claims. Having concluded that continuous monitoring was key to detecting preventable errors, we mandated minimal monitoring standards that would include what prudent anesthesiologists were already doing. We rejected "recommendations" and "guidelines." If approved by the anesthesia department chiefs, we would set the precedent that these basic rules should be followed by all anesthesia providers at our hospitals. We could and did add other standards over the next few years.2 While the emphasis was on practice behaviors, new technologies greatly exceeded the ability of human senses to detect changes in oxygenation and ventilation, providing earlier warning of adverse events. However, pulse oximetry was not included in the initial standards because it was quite new to the vast majority of anesthesia providers. There was no evidence that its use was efficacious or improved outcomes. Mandating the use of pulse oximetry at the time would have risked objections from some vocal, influential anesthesia faculty who might then have succeeded in blocking the entire effort. Even to this day, there are no well-controlled studies showing a statistically significant benefit on outcomes with pulse oximetry. While it is true that "not everything that counts can be counted (and not everything that can be counted counts)," such an argument to include pulse oximetry in the standards might not have been persuasive. Obviously, being able to detect oxygen desaturation before it reached critical levels had the potential to avoid anesthetic mishaps. Yet, until more experience with pulse oximetry was gained and a tipping point was achieved to induce its almost universal use, many considered it an interesting gimmick that needed to pass the test of time. The committee member who left the meeting room in frustration (James H. Philip) was prescient and later would be proven correct about the value of pulse oximetry. But, to achieve our main goals, we would have to wait a bit for that to play out, which it did soon thereafter. To illustrate this point, a quality assurance study of Recovery Room Impact Events (RRIE) began in 1985 at Massachusetts General Hospital (MGH), initially having nothing to do with pulse oximetry.3 Essentially, an RRIE was an anesthetic mishap that required intervention, impacted Recovery Room care, and did or could cause at least moderate morbidity. When the MGH installed pulse oximetry in every operating room on 1 day in January, 1986, we were able to compare the data collected on RRIEs in the several months before, and then after pulse oximetry was used routinely. Among the 12,088 patients studied, significantly fewer experienced any type of RRIE following pulse oximetry used during their anesthetics. Of course, cause and effect could not be determined. Importantly, there was no significant difference in hypoxic RRIEs before versus after routine use of pulse oximetry. Expecting a reduction in claims and payouts, Controlled Risk Insurance Company's promise to reduce malpractice premiums if the standards were adopted was the carrot to the stick of mandating standards. Indeed, anesthesia malpractice premiums plummeted over the next few years and have remained low nationwide, about one-third of their peak in the mid 1980s, thus constituting evidence (an alternative to "P < .05") that the practices (and facilitating technologies) of intraoperative safety monitoring effectively reduced the number and severity of anesthesia mishaps. An indirect but important effect of the standards was to help influence a culture change in patient safety. The biotechnology industry was incentivized to research, develop, and build better instrumentation for convenient, continuous monitoring, About the same time, Dr Ellison (Jeep) Pierce facilitated establishing the Anesthesia Patient Safety Foundation. The American Society of Anesthesiologists' (ASA)-Closed Claims Study showed that pulse oximetry and capnography prevented respiratory-related claims and poor patient outcomes.4 After extensive publicity in the lay press, the 1986 article about the Standards published in the Journal of the American Medical Association,5 led to the ASA's adopting the Minimal Monitoring Standards almost verbatim, and ultimately, internationally. In 2015, that article was listed as the tenth most important manuscript in the history of anesthesiology.6 We hope this information supplements the authors' superb review of this topic.1 David J. Cullen, MDDepartment of Anesthesia, Critical Care and Pain MedicineMassachusetts General HospitalHarvard Medical School (retired)Department of Anesthesia and Pain MedicineSt. Elizabeth's Medical Center and Tufts University School of Medicine (Retired)Boston, MA Jeffrey B. Cooper, PhDDepartment of Anesthesia, Critical Care, and Pain MedicineMassachusetts General HospitalHarvard Medical SchoolBoston, MA[email protected] John H. Eichhorn, MDDepartment of AnesthesiologyUniversity of Kentucky College of Medicine (Retired)Lexington, KY Ward R. Maier, MDDepartment of Anesthesia, Critical Care and Pain MedicineMassachusetts General HospitalHarvard Medical School (retired)Boston, MA James H. Philip, MDDepartment of Anesthesiology, Perioperative and Pain MedicineBrigham and Women's HospitalHarvard Medical SchoolBoston, MA Robert S. Holzman, MDDepartment of Anesthesiology, Critical Care, and Pain MedicineBoston Children's HospitalHarvard Medical SchoolBoston, MA

Department of Anesthesiology, University of Kentucky, Lexington, Kentucky The author declares that there is nothing to disclose. Address Correspondence to: John H. Eichhorn, MD, Anesthesiology, N-202, UKMC, 800 Rose St., Lexington, KY 40536-0293. E-mail: [email protected]

749 October 2013 W can you say to a patient having a skin lesion excised under monitored anesthesia care (MAC) who suffers severe burns to the neck and face from a surgical-site fire caused by unnecessary supplemental nasal cannula oxygen leaking under drapes and towels into the surgical field where electrocautery was used? “Oops!” is clearly insufficient. Although “I’m sorry” and then an outline of exactly what happened may be a start, there is often a significant difference between an explanation and an excuse. With the recent widespread emphasis on the risk of surgical-site fires and new knowledge about the flammability of surgical drapes and materials, there can be no excuse. In this issue of the journal, Culp et al.1 squarely address this emphasis on the risk of surgical-site fires that was echoed very recently in the report of the American Society of Anesthesiologists Closed Claims Study analysis of operating room fires.2 Culp et al. demonstrated the flammability of the drapes and towels used to create surgical fields and the sponges used during surgery. Furthermore, particularly, the authors showed huge (and dangerous) increases in flammability of these materials in oxygen-enriched environments. Some anesthesia professionals may think that this is intuitively obvious from basic chemistry, but it is the time measurements using stop-action video at 30 frames a second that provide their dramatic results. The authors used a standardized test method used for garment fabric and used a common match as an ignition source, which burns at 200°C less than the temperature of the spark from a monopolar electrocautery that burns tissue to stop bleeding. For a cotton surgical sponge, the ignition times were 0.9 s in 21% oxygen (room air), 0.3 s in 50% oxygen, and less than 0.1 s in 100% oxygen. Times for the standard-sized samples to burn completely were 27, 2, and 0.8 s, respectively. For the routine blue cotton towel that forms the edges of so many surgical sites, ignition was 1.6 s in room air and 0.1 s in 100% oxygen. Towel samples burned up completely within 22 s in room air and 0.9 s in 100% oxygen. These results showing increased flammability are both remarkable and consistent with the concept that most oxygenenhanced surgical-site fires occur so rapidly that even the quickest response from the operating team cannot prevent patient burns. The “paper drapes” commonly used to cover patients on the operating table (including the patient’s head and face during many procedures on the upper torso, neck, and head), which are mostly made of the organic polymer polypropylene, ignite and burn much faster in 100% oxygen (note that the surgical drapes burned in 81% of MAC case fires reported to the American Society of Anesthesiologists Closed Claims Study3 and that supplemental oxygen was being administered in 100% of those cases.) Even surgical gowns, which are almost entirely made of polypropylene and which do not ignite in room air, ignite and burn almost instantly in 100% oxygen. These findings show truly dramatic oxygen-enriched facilitation of flammability of the materials comprising a surgical field. They must serve as a warning to those anesthesia professionals who apparently still do not appreciate the great risks caused by open supplemental oxygen, usually from nasal cannulae covered by a drape over the head, leaking into a surgical site where electrocautery will be used. These practitioners still place nasal cannulae or even a perforated plastic face mask (preferred by some in order to keep the surgical drape off the patient’s face) and administer 2 or 3 l/min of oxygen for every single MAC case, including for perfectly healthy patients. This is done allegedly out of concern that IV “sedation” with benzodiazepines, narcotics, and hypnotics such as propofol will cause hypoxemia manifest as hemoglobin desaturation A Burning Issue

n engl j med 368;25 nejm.org june 20, 2013 2439 and clearly stated in our article that decisions about CPR should be individualized and informed by patients’ preferences and health status. However, discussions about patient preferences for CPR and subsequent treatments require information gathered and updated at different points in care. These discussions will obviously differ among patients who have recently survived cardiac arrest2 and those who have not had a history of cardiac arrest, and both are important conversations that physicians need to have with patients. Regarding conversations with the latter group, the 1-year and 3-year overall survival rates among patients who subsequently have a cardiac arrest are approximately 13% and 10%, respectively (on the basis of 2009 rates of in-hospital survival of 22.3%1), which far exceed in-hospital survival rates (4.6%) for patients with out-of-hospital cardiac arrest3 — a population for whom great efforts for resuscitation are undertaken. Indeed, we submit that many patients who are presented with a 3-year survival rate of 10% from the time of in-hospital cardiac arrest would not find CPR to be futile, as evidenced by their choices in other conditions, such as aggressive chemotherapy for advanced cancers.4

Conventional wisdom and traditional habits need to be challenged continually to help understand and, thus, advance clinical practice. Many features of routine anesthesia protocols have evolved over time because they seem logical and are faithfully drilled into trainees by well-meaning faculty members who learned them from their teachers, and so on…. In this issue of the journal, Remz and colleagues1 address the conventional teaching that reducing the inspired oxygen concentration will prevent an airway fire when an ignition source is used in the airway. All trainees see images of the dramatic "blowtorch ignition" of a plastic endotracheal tube through which 100% oxygen is flowing2 (simulating a recognized danger during a "simple, routine" tracheostomy)3–5 (Fig. 1). Airway fires are usually reported by otolaryngologists or anesthesiologists and have involved all types of surgery in the airway,6 including the common tonsillectomy.7 Ever since identification of the danger of a fire in a patient's airway, ignited by an electrocautery, a laser, or a fiberoptic light, the "wisdom" handed down has been that the inspired oxygen concentration delivered from the anesthesia machine should be made <30% (FIO2 <0.30) or reduced to the "minimum possible" to limit the dramatic increase in flammability of plastic, cloth, and tissue in an oxygen-enriched environment. Remz and colleagues1 posit that the real issue is not only the inspired oxygen concentration but also the expired concentration. Using a simulation model, they demonstrated that the relation between the 2 depends on several factors and, importantly, that expired oxygen concentration may be increased for a considerable period of time after the inspired concentration appears to be "safe," which could create an unexpected, occult risk of airway fire. These findings necessitate a reevaluation of our wisdom and expansion of conventional teaching to recognize the role of expired oxygen in mitigating the risk of airway fires.Figure 1: Demonstration of rocket-like flames shooting from a tracheal tube caused by laser ignition of the tube with 100% oxygen flowing. Image courtesy of ECRI Institute.The American Society of Anesthesiologists Practice Advisory for Prevention and Management of Operating Room Fires8 states that the consultants and American Society of Anesthesiologists members strongly agree that for high-risk procedures where an ignition source is in proximity to an oxidizer-enriched atmosphere, the inspired oxygen fraction (FIO2) delivered to the patient should be kept "as low as clinically feasible." Regarding use of an ignition source to enter or work in the trachea when the patient's lungs are being mechanically ventilated via a tracheal tube, the American Society of Anesthesiologists advisory cites a survey asking practitioners how much time did they believe was needed to reduce oxygen (or nitrous oxide) concentration to a safe level before using an ignition source.8 The answers ranged from <1 to 10 minutes (mean 2.9 minutes). These values likely reflect real-world experience in clinical anesthesia practice, in which there is a wide spectrum of lung function and pathology, leading to variation in time constants and, thus, in washout time of the high concentration of oxygen. Remz and colleagues1 used a mechanically ventilated human patient simulator with routine settings. Starting with inspired oxygen concentrations of 100% and 60% in the breathing circuit, they replaced the original oxygen-rich fresh gas flows (FGF) with air (21% oxygen) and repeatedly measured inspired and expired oxygen concentrations at the Y-connector over time, until both oxygen concentrations were <30% (the alleged maximum concentration recommended when a laser is used in the airway). Using this model, they studied the replacement FGF of air at 2 L/min and 5 L/min and also compared short (fully compacted) and long (fully extended) breathing circuits. The results were illuminating. As would seem intuitive, the oxygen concentrations took longer to decrease to <30% when starting from 100% vs starting from 60% oxygen. Likewise, the oxygen concentrations decreased much more quickly at the higher FGF of air and somewhat faster in the short circuits versus the long ones (but not as much as might have been expected based on the large difference in volumes). The core results involved the comparison of the decrease over time in the inspired versus expired oxygen concentrations to <30%. With 5 L/min FGF of air into 100% oxygen (long circuit), the inspiratory concentration took <1 minute to fall, while the expiratory concentration took nearly 3 minutes. At 2 L/min FGF of air, paradoxically, the inspiratory concentration decreased in 8 minutes, and the expiratory concentration decreased in 7 minutes. The remarkably slow decreases in circuit oxygen concentration at the lower FGF of air are very important for fire risk considerations. A wait of 7 or 8 minutes will seem like an eternity to an impatient surgeon holding a cautery pencil or laser probe. Also, the observation that the expiratory concentrations track the inspiratory concentrations closely at low FGF of air (and, in fact, decreases slightly faster) may seem counterintuitive. One possibility is that this is related to the oxygen consumption rate of the simulator, but, in any case, this phenomenon deserves further study. However, it is more important to emphasize the key finding that at high FGFs (which are much more likely to be employed when the transition to air is made; otherwise, the wait would seem interminable), the decrease in expired oxygen concentration is significantly slower than for the inspired concentration. Thus, in such situations, using the inspired oxygen concentration as the basis for signaling the impatient surgeon to activate the cautery or laser would be dangerous. An oxygen-enriched environment persists (the expiratory phase is usually two thirds of the ventilatory cycle) and, thus, there is a dramatically increased risk of airway fire when cautery or a laser is used. One potentially important factor that was not studied by Remz and colleagues1 following switching from 100% or 60% oxygen to air was the effect of minute ventilation on the decrease in expired oxygen concentration. In their study, they used a minute ventilation set to 4 L. It is well established that to achieve a desired concentration of a gas in the lungs (in this case, to <30% oxygen), the 2 important variables are the FGF (in this case, of air) and minute ventilation.9 This is, after all, how we speed a patient's emergence (anesthetic washout) following the administration of an inhaled anesthetic.10 Establishing the interaction between FGF of air and minute ventilation on the rate of decrease in expired oxygen concentration would certainly have clinical application during "deoxygenation" before the use of an ignition source. It seems intuitively obvious that increasing both FGF of air (e.g., to 10 L/min) and minute ventilation (e.g., by 50%) would substantially decrease the time to achieve an expired oxygen concentration of <30% and, thus, is recommended in such situations. Despite the conventional wisdom concerning decreasing the oxygen concentration, airway fires continue to occur. The number of these fires is unknown because there is no mandatory reporting to a centralized registry. Remz et al.1 cite the often-quoted annual estimate by ECRI of >120.11 If, for example, a "blowtorch" fire of an endotracheal tube during a tracheostomy caused a patient's death, that would require reporting to The Joint Commission as a "sentinel event." An airway fire should be a "never event," something that simply should never happen and that should be reported to the appropriate regulatory and accrediting entities so that education occurs, and warnings can be generated to help prevent similar events in other patients. In that vein, airway fires are featured in the dramatic and effective Anesthesia Patient Safety Foundation's "Fire Safety Video"a that also covers fires during monitored anesthesia care for superficial surgery on the upper body with open delivery of supplemental oxygen underneath drapes. Airway fires were also included in the analysis of the American Society of Anesthesiologists Closed Claims Database reports of operating room fires.12 Ten of the 103 cases since 1985 were airway fires in intubated patients, 4 during tonsillectomy and 6 during tracheostomy. In the tonsillectomy cases, an uncuffed endotracheal tube or a leak around an endotracheal tube cuff was reported as the oxidizer source. Thus, overall, while airway fires may be relatively infrequent, they do occur, can be severely injurious, and also should be preventable with awareness and precautions. Regarding potentiation of conventional wisdom, an erudite and extensive discussion of endotracheal tube fires in airway laser surgery13 states only: "…most clinicians recognize the need to reduce the FIO2 to <0.40 or to the minimum concentration consistent with patient oxygenation." There are no references and no mention of time course or expired oxygen concentration, illustrating the knowledge gap addressed by the data reported by Remz and colleagues.1 Overall, in the (relatively infrequent) cases where the patient truly is dependent on supplemental oxygen for survival during the surgery, the logical approach is to decrease the inspired and expired concentrations to the absolute minimum necessary and then warn the surgeon that there is an increased risk of fire if he/she uses an ignition source. In this way, preventive precautions can be used in the surgical field, which would include not using the ignition source at all in appropriate circumstances. Furthermore, Remz and colleagues1 address the often-cited protocol response to an airway fire (previously a perennial question on the written anesthesiology board certification examination) by correctly raising the question of the implication of the lag in decrease of expired oxygen concentration after changing the FGF to air. If an airway fire should occur shortly after the switch to inspired air, initially disconnecting the breathing circuit from the tube or stopping the FGF (the traditional conventional wisdom) may actually be detrimental to the situation because that leaves in the airway only the oxygen-enriched expired gas that would be more likely to support vigorous combustion. Remz and colleagues1 recommend leaving the circuit with air flowing connected and simply immediately pulling out the tube. This is controversial and deserves research and further consideration. However, it seems logical and, until proven otherwise, should be done. The results presented by Remz and colleagues1 challenge conventional wisdom and provoke critical thinking. However, as can often be the case, how 1 dataset from a simulation experiment such as this should influence daily clinical practice is not completely clear. Another study, employing high-flow oxygen through an endotracheal tube into a gutted chicken carcass, showed no ignition by electrocautery of the tissue or tube at oxygen concentrations <45%.14 How might that observation relate to this question? It seems unlikely that there will be definitive research in the foreseeable future demonstrating that it is safe to maintain high airway oxygen concentrations during use of ignition sources. Accordingly, the reconsidered new wisdom should be that during airway cases, particularly tracheostomy, tonsillectomy, and laser surgery, the minimum possible oxygen concentration consistent with adequate patient oxygenation should be utilized. Monitoring of both inspired and expired oxygen concentrations appears to have advantages, particularly in airway cases. The current American Society of Anesthesiologists Standards for Basic Anesthetic Monitoring,15 under "Oxygenation" have the stated objective: "To ensure adequate oxygen concentration in the inspired gas," and under "Methods: Inspired Gas": "During every administration of general anesthesia using an anesthesia machine, the concentration of oxygen in the patient breathing system shall be measured by an oxygen analyzer with a low oxygen concentration limit alarm in use." Thus, the concern has been to avoid delivery of a hypoxic gas mixture to the patient. Further, the most recent voluntary consensus standard applicable to the anesthesia workstation requires an oxygen monitor in the inspiratory limb or at the Y-piece.16 Most commonly, an oxygen analyzer is located in the vicinity of the inspiratory unidirectional valve in the circle breathing system. Many, if not most, anesthetizing locations now have multigas analyzers that sample respired gas from an adapter at the patient's airway and measure both inspired and expired gas concentrations, including those of oxygen, on a breath-by-breath basis. These analyzers may be integral with the anesthesia workstation or free-standing units. In these devices, oxygen concentration is measured by a rapidly responding paramagnetic analyzer that provides inspired and end-tidal oxygen concentrations and a display of the oxygram (analogous to the familiar capnogram).17 Monitoring of end-tidal oxygen concentration has proven valuable in confirming the adequacy of preoxygenation prior to induction.18 Importantly, concerning airway fires, it serves as a monitor of deoxygenation in anticipation of activation of an ignition source. With increasing prevalence of these multigas analyzers, monitoring of expired oxygen concentration will become increasingly routine, including as a feature to help prevent airway fire. If, in anticipation of activation of an ignition source, the FGF containing supplemental oxygen is appropriately switched to air at a high-flow rate, the anesthesia practitioner should wait and watch until the oxygen concentration of both inspired and expired gas has fallen well into the safe range (arguably <30%) before authorizing the use of an ignition source. Increasing the minute ventilation in addition to FGF of air should accelerate the attainment of the safe range. All of this requires vigilance and good rapport and communication with the surgeon. Diligent application of such a protocol should, indeed, help to make airway fires a never event. DISCLOSURES Name: John H. Eichhorn, MD. Contribution: This author helped write the manuscript. Attestation: The author approved the final manuscript. Name: James B. Eisenkraft, MD. Contribution: This author helped write the manuscript. Attestation: The author approved the final manuscript. This manuscript was handled by: Sorin J. Brull, MD, FCARCSI (Hon).

professionals everywhere to recognize the implications of the flammability of surgical drapes and materials and, especially, the dramatically increased flammability in oxygen-enriched environments.Patient burns from surgical-site fires in superficial upper body surgeries conducted under MAC can be prevented right now.This will happen when new practice habits are formed, and inappropriate open-source supplemental oxygen under closed drapes is eliminated-due to the new version of … "That's what I was taught; it's the way we always do it."

A 48-year-old woman presented after routine tomosynthesis had revealed a lesion in the left breast. Core-biopsy and lumpectomy specimens showed ductal carcinoma in situ, with positive margins. Management decisions were made.

Purpose This brief review provides an overview and, importantly, a context perspective of relevant current practical issues in perioperative patient safety.Principal findings The dramatic improvement in anesthesia patient safety over the last 30 years was not initiated by electronic monitors but, rather, largely by a set of behaviours known as "safety monitoring'' that were then made decidedly more effective by extending the human senses through electronic monitoring, for example, capnography and pulse oximetry. In the highly developed world, this current success is threatened by complacency and production pressure. In some areas of the developing/underdeveloped world, the challenge is implementing the components of anesthesia practice that will bring safety improvements to parallel the overall current success, for instance, applying the World Federation of Societies of Anaesthesiologists (WFSA) "International Standards for A Safe Practice of Anaesthesia''. Generally, expanding the current success in safety involves many practical issues. System issues involve research, effective reporting mechanisms and analysis/broadcasting of results, perioperative communication (including "speaking up to power''), and checklists. Monitoring issues involve enforcing existing published monitoring standards and also recognizing the risk of danger to the patient from hypoventilation during procedural sedation and from postoperative intravenous pain medications. Issues of clinical care include medication errors in the operating room, cerebral hypoperfusion (especially in the head-up position), dangers of airway management, postoperative residual weakness from muscle relaxants, operating room fires, and risks specific in obstetric anesthesia.Conclusions Recognition of the issues outlined here and empowerment of all anesthesia professionals, from the most senior professors and administrators to the newest practitioners, should help maintain, solidify, and expand the improvements in anesthesia and perioperative patient safety.

Dr.Peter Venkman说:"擤掉的鼻涕,你想留着它吗?" ——Ghostbusters (1984) 我们身上的数字极其庞大!我们每个人由大约10万亿个细胞构成,伴随着的是共生在我们体内或体表的由100万亿个微生物构成的个人微生物群.手术部位感染只是这种众多和平共处的复杂特性之一.这些微生物影响了我们的进化,它们对消化、代谢和免疫至关重要;同时它们也充当了我们的传染源.从2007年,国立卫生研究院已经资助国际人类微生物群的研究项目,该项目致力于研究我们身上的微生物群对人类每一个个体的独特性和对人类这一种群的普遍性[1,2].我们的微生物丛的分布类似于生物膜,尤其令人印象深刻的是,它们的结构就像在细胞外聚合物的三维母体内形成的社区,细菌就附着在上皮膜的表面[3].目前公认,慢性细菌感染是细菌表面的生物膜限制了宿主抗体和巨噬细胞的进入,也阻止了抗生素的扩散[3-6].同一个种属细菌的生物膜可能在一个人体的某个部位是不致病的,而在另一个部位却是致病的.例如,手术部位感染的最常见致病菌是化脓性金黄色葡萄球菌[7],这个部位感染的定义:发生于手术后30天内,如果术中有植入物的则定义为1年内.然而,我们当中有20％是鼻前孔化脓性金黄色葡萄球菌的持续、无症状带菌者,30％是间断性带菌者[8].因为我们的生物膜上持续不断的脱落着细菌[6,9],所以作为患者或医务人员的我们,污染着我们所进入的每一间手术室[9-14].

The Anesthesia Patient Safety Foundation (APSF) was created in 1985. Its founders coined the term "patient safety" in its modern public usage and created the very first patient safety organization, igniting a movement that is now universal in all of health care. Driven by the vision "that no patient shall be harmed by anesthesia," the APSF has worked tirelessly for more than a quarter century to promote safety education and communication through its widely read Newsletter, its programs, and its presentations. The APSF's extensive research grant program has supported a great many projects leading to key safety improvements and, in particular, was central in the development of high-fidelity mannequin simulation as a research and teaching tool. With its pioneering collaboration, the APSF is unique in incorporating the talents and resources of anesthesia professionals of all types, safety scientists, pharmaceutical and equipment manufacturers, regulators, liability insurance companies, and also surgeons. Specific alerts, campaigns, discussions, and projects have targeted a host of safety issues and dangers over the years, starting with minimal intraoperative monitoring in 1986 and all the way up to beach-chair position cerebral perfusion pressure, operating room medication errors, and the extremely popular DVD on operating room fire safety in 2010; the list is long and expansive. The APSF has served as a model and inspiration for subsequent patient safety organizations and has been recognized nationally as having a dramatic positive impact on the safety of anesthesia care. Recognizing that the work is not over, that systems, organizations, and equipment still at times fail, that basic preventable human errors still do sometimes occur, and that "production pressure" in anesthesia practice threatens past safety gains, the APSF is firmly committed and continues to work hard both on established tenets and new patient safety principles.

Anesthesiology, with its development of practice standards, helped create the patient safety movement, states Dr. Eichhorn, and "can continue to be the role model and to lead the way in patient safety for all of health care.

Anesthesiology, with its development of practice standards, helped create the patient safety movement, states Dr. Eichhorn, and "can continue to be the role model and to lead the way in patient safety for all of health care.