While anesthesiology has been at the forefront in advancing patient safety, as a specialty it has continued to define ways to better evaluate care and outcomes and identify ways to further reduce complications. ASA has initiated a number of important programs to improve tracking of critical incidents, utilizing the National Anesthesia Clinical Outcomes Registry (NACOR) and Anesthesia Incident Reporting System, simulation training for crisis management, integration of new technology such as point-of-care ultrasound and ultrasound-guided peripheral nerve blocks into clinical practice, and perioperative pathways such as Enhanced Recovery After Surgery and the Perioperative Surgical Home. While these programs have been broadly adopted and successful, additional efforts are required to continue to advance patient safety across the entire perioperative environment. Opportunities exist to improve interactions between the anesthesiologist and the environment, transform safety culture and communication, and expand the work of anesthesiology to the health care system as a whole. What can we look forward to in anesthesia patient safety in 2030?
The anesthesiologist and the machine
Anesthesiology has always embraced technology to advance and optimize clinical care. Medical devices used in anesthesia practice have improved considerably, incorporating fail-safe mechanisms and improved feedback to prevent unintended misuse or complications. At the same time, medical technology has advanced and expanded to include new technologies, clinical decision pathways, and other approaches to care. The growth of these new technologies is occurring at an exponential rate; the days of esophageal stethoscopes and bellows ventilators are long gone. Clinical decision support in electronic health records, machine learning, and artificial intelligence (AI) are becoming prominent in clinical practice, and advancements in clinical devices continue to accelerate over time. These advances can be beneficial for patient safety. For example, machines may be more adept at detecting very subtle changes in clinical status than human vigilance. Clinical decision support, increasingly powered by machine learning and AI, aims to alert clinicians to best practices suited to individual patient characteristics.
While these advances have and will continue to improve patient safety, the use of technology and automation also poses a threat. Problems with automation include under-reliance or overreliance on technology, degradation of manual skills, and the inability to manage systems failures. Increased exposure to alerts may desensitize clinicians to those alerts that may be beneficial for patient care. While devices used in the OR have become immeasurably more complex, education on how to use these devices has not advanced at the same rate. In the future, more attention must be paid to improve training and utilize simulation to ensure that every provider understands how these more complex systems work, conditions under which they can be trusted, and how to address device failures. Such training must target those in training and ensure that anesthesiologists in established clinical practice maintain their knowledge and skills to utilize technology appropriately and understand its limitations.
Burnout as a patient safety threat
Patient safety depends critically on well-rested, engaged, and vigilant care team members. Burnout, a phenomenon endemic in medicine, is therefore a direct threat to safety in a complex system such as perioperative care. Multiple meta-analyses examining burnout in physicians have found an association between physician burnout and lower safety-related quality of care. Both poor provider well-being (such as depression and anxiety) and burnout are significantly associated with increased medical errors. Contributors to burnout include production pressure, lack of control over schedule, and the high-stress nature of acute patient care.
Anesthesiology ranks among the specialties with the highest rate of burnout, and residents, in particular, may be at even higher risk. Given the progressively high stress, complexity, and acuity of anesthesiology work, we anticipate that physician burnout and poor well-being will continue to pose a threat to patient safety in 2030. In a survey of anesthesiologists performed prior the start of the COVID-19 pandemic, 59.2% were found to be at high risk for burnout17 compared to 44% of physicians nationwide. Even more alarming is that 51% of U.S. anesthesiology residents and first-year graduates report burnout. If a general shift in approach is not taken, this trend will only continue and will, in fact, worsen as anesthesiologists are expected to care for more medically complex patients in more challenging environments. For this reason, specialty-wide changes must be undertaken to mitigate the effects of burnout. Studies have shown that both individually and organizationally focused interventions may help, though individually focused interventions are not as effective as those focused at organizations. Training in mindfulness and resilience may alleviate stress on the individual level, while organizational changes that promote work schedule flexibility, work-life integration, and interprofessional teamwork have been effective in decreasing burnout as a whole. Over the next decade, medicine in general and anesthesiology in particular must put increased attention to developing and implementing system interventions designed to reduce burnout and its implications for personal well-being and patient safety.
Safety outside the OR
As anesthesia practice continues to expand beyond the OR, unique safety concerns emerge as a result of new environments of care and their implications. Non-operating room anesthesia (NORA) has expanded significantly in the past 10 years, presenting both threats to and opportunities for improvement in patient safety and safety culture. NORA cases pose significant challenges to patient safety given its remote location from supplies, pharmacy, and support staff, including additional skilled anesthesia help. Although there are proportionally fewer malpractice claims for NORA compared to OR locations, there is a higher proportion of claims for death in NORA compared to the OR. The majority of the claims were the result of oversedation and inadequate oxygenation and ventilation. As the development and advances in new medical technology allow for increasingly complex procedures to be performed in progressively sicker and complex patients, we must continue to provide and adapt anesthesia services and support for care in remote locations without compromising our high standards for safety.
Failure to rescue (FTR) – the failure to prevent patient deterioration and death after complications of medical care or underlying illness – is also a growing area of attention in patient safety that creates opportunities to improve identification of potential need for rescue as well as ways to respond more quickly and successfully to minimize risk. Barriers to timely rescue include inadequate staffing levels and education, lack of early warning systems and detection of deteriorating patients, communication barriers between patients and providers, lack of effective handoff communication, and poor institutional ability to respond to the deteriorating patient. Further work must be done to identify and implement evidence-based strategies and interventions to combat FTR. This includes efforts to create and disseminate early warning systems for all perioperative patients as well as develop effective electronic warning systems. Improving FTR also requires continued work on identifying and optimizing handoff communication perioperatively. While organizations such as the Multi-Center Handoff Collaborative (handoffs.org) are working on improving handoff communication, continued research is needed on identifying and optimizing perioperative handoff communication during transfer of care so that no patient is harmed from preventable errors or information loss during transfer of care.
Culture of safety
Having a healthy culture of safety is critical to maintaining patient safety in the perioperative arena; in fact, can mitigate many of the potential threats posed by technological advances, physician burnout, anesthesia care outside of the OR, and FTR. According to the Agency for Healthcare Research and Quality, a healthy culture of safety requires acknowledgement of the high-risk nature of medicine, blame-free reporting of adverse events, and engagement of both frontline clinicians and leaders in the search for improvements in patient safety. Although significant progress has been made in shifting the focus of adverse event investigation from “blame and shame” to systems-focused improvement, many institutions still employ a reactive response to error, where analysis is undertaken of things that go wrong (Safety I). In the next 10 years, institutions should explore how things go right and why patient care is as safe as it is, celebrating successes in patient safety along the way (Safety II). Such culture-focused efforts should acknowledge that safety cultures may differ at the level of the institution and departments, divisions, and service lines. It is therefore possible for an institution to report a positive safety culture while the anesthesia care team has safety vulnerabilities, or vice versa.
Safety culture also includes an awareness of human fallibility and the need to structure systems and workflows to optimize performance. Human factors engineering and systems engineering approaches to understanding the complex work system – like the Systems Engineering Initiative for Patient Safety – can help identify and mitigate vulnerabilities related to cognitive overload, fatigue, and other factors. Checklists, protocols, smart alarms, and medication bar coding are all examples of low- and high-tech tools that support human work in the high-risk perioperative environment.
Anesthesiologists have long been leaders in patient safety. As anesthesiologists, we have valuable skills in situational awareness, scenario planning, disaster preparedness, simulation, and multidisciplinary teamwork, and we interface with multiple specialties within and outside the hospital. This positions anesthesiologists to be ideal champions for patient safety as new challenges emerge in the coming years. Opportunities to lead in safety present themselves on the front lines of care, as leaders within our departments and practices, at institutional and executive levels, and in organizations such as payers, grant funders, and foundations. The anesthesiologist of 2030 should be equipped with patient safety-relevant skills, including fluency with data and technological innovation, leadership, and change management. These skills and more are vital to ensuring our specialty’s ability to anticipate and respond to the patient safety challenges outlined here and the inevitable emerging challenges that will present themselves by the year 2030.