Anesthesia Patient Safety Update

December 2011
APSF Announces Availability of Medication Safety DVD
An 18 minute educational DVD, Medication Safety in the Operating Room: Time for a New Paradigm, will be available for viewing on the APSF website ( beginning January 2, 2012.  A complimentary copy of the DVD will also be available by completing the request form on the website.  This educational video emphasizes the STPC paradigm(Standardization, Technology, Pharmacy/Prefilled/Premixed and Culture) and its potential role in improving medication safety in the operating room.
APSF Announces Conference on Postoperative Visual Loss (September 12, 2012, Phoenix, Ariz.)
APSF believes that increased awareness and understanding of risk factors associated with postoperative visual loss (POVL) is a timely patient safety topic.  Peer-review literature including an article to be published in the January 2012 issue of Anesthesiology and data from the American Society of Anesthesiologists (ASA) POVL Registry are evolving in a manner that suggest a patient profile at risk for POVL and steps to take in the surgical and anesthetic management that might decrease the incidence of this devastating complication. The goals of this one-day multidisciplinary are to assure that current management reflects evolving information and understanding of “best practices” for patients at risk for POLV.  Please contact Dr. Stoelting for registration information (
Operating Room Fire Safety Video Survey
APSF had conducted a survey (24 questions) of the 542 anesthesia professionals who requested the Operating Room Fire Safety Video between its introduction in April 2010 and October 2011. The goal of the survey was to evaluate the impact of this educational video on how anesthesia professionals approach the administration of supplemental oxygen to “at risk patients for operating room fires.” Survey responses (30 percent response rate) indicated the DVD increased recognition by anesthesia professionals of at-risk patients and changed practice related to administration of supplemental oxygen via open delivery systems.  A complete set of the survey responses may be obtained upon request (
APSF Fire Prevention Algorithm
Prevention of surgical fires is a team effort including communication among all the caregivers, prudent use of supplemental oxygen by the anesthesia professional, proper use of topical alcohol-based disinfectants by nursing and surgery and appropriate use of ignition sources by the surgeon.  APSF recognizes that flash fires occurring on the body surface during operations above T5 often include delivery of supplemental oxygen via an open delivery system creating an oxidizer enriched atmosphere in proximity to an ignition source.  In an effort to increase awareness for the potential of surgical fires in at risk patients.” APSF is proposing a “Fire Prevention Algorithm” that will be published in the Winter 2012 issue of the APSF Newsletter.


APSF Board of Directors Workshop, Current Anesthesia Patient Safety Issues-Help Set the Priorities for Immediate Short-Term Resolution (Saturday, October 15, 2011, McCormick Place Convention Center, Chicago, Ill.)
Critiques of the safety presentations and Responses to the Audience Response Questions posed at the APSF Board of Directors Workshop may be viewed on the APSF website (  under Announcements.  Of interest for each safety topic presented the speakers concluded that “we have evidence/agreement for the etiology of the problem” and “anesthesia has control/influence over introducing the solution to the problem.”  A report of the workshop proceedings will be published in the Winter 2012 issue of the APSF Newsletter.