Just 20 years ago, anesthetic choices were limited, practice guidelines didn't exist, anesthesia technology was still in its infancy and about one in every 5,000 surgical patients died from anesthesia-related complications. We anesthesiologists were considered among the riskiest physicians to insure - our average malpractice premiums soared to more than $30,000 per year.

Then came the meteoric rise of outpatient surgery, which demanded that anesthesia providers ensure safe anesthesia and rapid recovery. The specialty has stepped up to the plate, developing drugs, devices and processes that let many patients leave our facilities clear-headed and practically pain-free, sometimes less than an hour after their procedures. Anesthesia-related deaths have dropped to one per 200,000 to 300,000 anesthetics administered and annual malpractice rates for anesthesiologists have dropped by more than $10,000. Even the Institute of Medicine's landmark 1999 report on medical errors, To Err is Human, lauded anesthesia for its commitment to patient safety.

Here are seven factors that have helped make anesthesia a model of safety and ingenuity that other specialties are hoping to emulate.

The Closed Claims Project: Learning from our mistakes.
The Closed Claims Project, which the American Society of Anesthesiologists established in 1985, marked the first time any medical specialty had tried, in a coordinated and systematic way, to learn from its mistakes. The project aimed to examine malpractice claims settled by insurance companies; identify patterns of errors that had led to patient injuries and subsequent litigation; and determine where to focus safety improvement activities.

Project data revealed respiratory-related events were the most frequent cause of liability, and that many of these occurrences could have been prevented. This information spurred the ASA to develop guidelines on airway management and the industry to develop new tools, such as pulse oximeters, capnographers and laryngeal mask airways. Respiratory-related claims dropped, but more importantly, thousands of lives were saved.

To date, the Closed Claims Project has reviewed more than 6,894 claims; 300 more are added each year. Most recently, the data has prompted a new focus in pediatric post-operative cardiac arrest and perioperative ischemic optic neuropathy. Other specialties have taken notice - the American College of Surgeons launched its own closed claims project last year.

Development of anesthesia guidelines.
The ASA's evidence-based guidelines and best-practice parameters address a variety of clinical situations and procedures, from basic anesthesia monitoring to guidelines for administering ambulatory anesthesia. These standards have helped ensure that all surgical patients receive a consistent level of care.

Many of you have used the guidelines as a foundation for developing your own policies on pre-operative evaluation and testing, discharge criteria and monitoring. This has made anesthesia providers much more adept at screening patients, asking just the right questions to catch potential problems (such as sleep apnea or latex allergy) and determining if that patient is taking medications that might interfere with anesthesia, says Rick Hoffman, a CRNA at Greene Memorial Hospital and Beaver-creek Surgery Center in Beavercreek, Ohio.

In addition, says Jay Horowitz, CRNA, president of Quality Anesthesia Care Corp. in Sarasota, Fla., pre-operative screening gives anesthesia providers a chance to educate patients. "I call all my patients ahead of time, get a medical history, and let them know, detail by detail, what they can expect before and after their procedure," he says. "This kind of pre-operative teaching always leads to better, safer recovery."

Safer, short-acting drugs.
Advances in pharmacology have led to short-acting anesthetics, analgesics and muscle relaxants that allow for rapid, smooth and safe induction and recovery. Propofol remains the gold standard of IV anesthetics; other important drugs include short-acting inhaled anesthetics such as desflurane and sevoflurane, and short-acting opioids such as remifentanil. PONV drugs have also vastly improved treatment of anesthesia's big little problem.

"In the last decade we've come to understand PONV much better, and we've added the 5-HT3 class of drugs to the many other categories of drugs that can effectively prevent or treat it," says Kathryn E. McGoldrick, MD, the president of the Society for Ambulatory Anesthesia. "Additionally, we now appreciate the role of combination therapy. By using two or three antiemetics with different mechanisms of action, we can achieve better outcomes for patients at high risk for PONV."

But it's not just the drugs themselves that have gotten better - our understanding of their mechanisms of action, our ability to use them to exploit the most beneficial effects of each drug, and our development of local and regional techniques have all led to better and safer anesthesia and more effective post-operative analgesia.

Improved drug delivery.
Improvements in drug delivery systems, including anesthesia machines and infusion pumps, have made anesthesia administration more effective and safer. Many anesthesia machines can now detect hypoxic mixtures and have built-in ventilators, precluding the need to manually ventilate patients and letting us safely care for patients with respiratory problems. We have a wide choice of therapy-specific infusion pumps to deliver general IV anesthesia, epidural anesthesia and peripheral nerve blocks more effectively and safely.

In addition, more surgical facilities are adopting patient warming techniques, which help patients metabolize anesthetic agents more quickly. Studies also suggest warming prevents post-op infection, aids in blood coagulation and prevents shivering.

Better basic monitoring.
Non-invasive blood pressure monitors, pulse oximeters and capnographers have all become more sophisticated and easier to use. They've also become more accurate - today's pulse oximeters, for example, are able to control for patient movement, allowing consistently precise readings. Some argue that electroencephalography-based monitoring (consciousness monitoring) that measures the depth of hypnosis also contributes to patient safety by preventing incidences of intraoperative awareness, but this is highly controversial (see "Mind Reader?" on page 57). At its annual meeting last month, the ASA approved its practice advisory on intraoperative awareness and brain function monitoring, which recommends further study of the technology and leaves the decision of whether to use it in the hands of the provider.

More advanced tools.
The Closed Claims Project clearly identified inadequate airway management as a major problem. Manufacturers in turn have developed more effective ways to maintain the airway.

• Tracheal tubes and laryngoscopes. These tools let providers isolate the trachea and deliver anesthetics safely while still maintaining adequate ventilation.
• LMAs. The LMA is now used for routine elective surgical procedures as frequently as the tracheal tube. The LMA has been incorporated into the ASA's Practice Guidelines for Management of the Difficult Airway.
• Non-cutting needles. Spinal anesthesia, which might be used for outpatient procedures such as a D&C or knee arthroscopy, has become a lot safer with the advent of non-cutting, pencil-point spinal needles, says Dr. McGoldrick. Use of these needles has led to a dramatic reduction in post-op headaches, which are caused by intracranial hypotension that occurs when the needle pierces the dura and spinal fluid leaks out. The loss of cerebrospinal fluid puts pressure on intracranial structures, causing what can be an excruciating headache. Non-cutting needles cause less damage to the dura, so that less fluid leaks out. "Studies show that the incidence of spinal headache with a non-cutting needle is typically one to two percent, compared with incidences perhaps as high as 15 percent for high-risk patients (such as young females) with traditional spinal needles," says Dr. McGoldrick.

An ongoing commitment to improvement.
Many anesthesia training programs are using lifelike patient simulators to give clinicians experience in detecting and treating rare but potentially fatal conditions such as malignant hyperthermia and anaphylactic shock, says Dr. McGoldrick. "In practice, a clinician might only see these conditions once in 15 or more years," she says. "The simulators give anesthesia residents a chance to see these conditions and learn how to deal with them."

In addition, the wide variety of anesthesia resources on the Internet (see "Anesthesia on the Web" for a few) has been very beneficial for anesthesia providers, says Mr. Hoffman. Providers can easily look up a drug or ask a question about a difficult case and get answers from colleagues around the country, he says.

Further, the ASA and the Society for Ambulatory Anesthesia have continued to fund research and outcomes studies on patient safety. The ASA has created two organizations to focus solely on patient safety: the Anesthesia Patient Safety Foundation, which was formed to improve knowledge of anesthesia safety issues; and the Foundation for Anesthesia Education and Research, whose mission is to raise the standards of the specialty by fostering education, research and scientific progress in anesthesiology. To date, the ASA has spent more than $16.5 million on patient safety efforts.