Chair, Patient Safety and Quality Committee (PSQC)
No doubt – patient safety is a recognised top health care and public health priority. No doubt – the preeminent importance of patient safety is acclaimed at medical conferences, in professional articles, and in the general media. And no doubt, much has been done in the last decades to raise awareness of preventable patient harm. With the Helsinki Declaration on Patient Safety in Anaesthesiology (HD),1 the EBA and the ESA have contributed a unique framework of practical safety requirements for anaesthesiology departments. This document has been signed by all European National Anaesthesiologists Societies (NAS), and by many international societies.
Despite these great intentions, the actual translation of these safety requirements into practice seems a rather slow process. A survey of NAS representatives two years after the launch of the HD indicated that adoption of the HD requirements was incomplete in most European countries.2 A 2014 review concluded that the majority of countries still had to ‘overcome some hurdles’ to achieve this goal, despite the tools provided by the ESA to facilitate translation into practice such as the Patient Safety Starter Kit 3 Seven years after the launch of the HD, many colleagues in anaesthesiology share these impressions – but the extent, the possible local variations, and the underlying causes of these shortcomings remain unclear.
Consider a practical example: A recent case report by the Spanish incident reporting system SENSAR described a situation of inadequate management of a difficult airway4 in a woman scheduled for parathyroidectomy. Fiberoptic intubation had been recommended during pre-anaesthesia consultation due to several predictors of a difficult airway. Despite this recommendation, direct laryngoscopy was eventually chosen for intubation. However, this proved to be difficult, and changing to a videolaryngoscope resulted in additional difficulties of handling and tube insertion. After several attempts, the patient was successfully intubated, but suffered from minor injuries to the lingual mucosa. Analysis of the reported incident helped to identify factors that had contributed to inadequate management: inexperience of the person managing the airway, the airway characteristics of the patient, and the absence of protocols on difficult airway management. These conclusions led to implementation of a difficult airway algorithm in the hospital, as well as to other activities dedicated to improving airway management.
This case report illustrates the need for, as well as opportunities offered by, the implementation of the HD requirements. Several years after the launch and publication of the HD, this hospital still did not have a protocol for difficult airway management – one of the principal requirements of the HD.1 As the report stated, ‘lack of experience’ of the involved professionals significantly contributed to the incident – indeed, training and verification of clinician’s ability to use equipment correctly and safely is required by the World Federation of Societies of Anaesthesiologists’ International Standards for a Safe Practice of Anaesthesia, which the HD has endorsed.5 On the positive side, an incident report was filed about the mishap in line with the HD requirement to contribute to a critical incident reporting system. This triggered significant improvements regarding the institution’s approach to airway management. By reporting an apparently minor incident, weaknesses of the local system were identified. Fixing them presumably contributed to preventing more serious future harm. The HD provides a useful roadmap to identify and resolve comparable system weaknesses.
Consistently, the ESA Board has prioritised the implementation of the HD. The PSQC has started to work on a project designed to assess and improve the adoption of the HD requirements. Several industry partners have agreed to support this project. Patient safety and the implementation of recommendations and policies are essentially major public health issues that require public health methods adapted to the complex structure and processes of perioperative healthcare. The methodical part of the projects therefore requires multi-professional cooperation with partners that can contribute their expertise in epidemiology and implementation. Multi-method approaches to data collection (e.g., surveys, registry analyses), integration of findings with existing information, and revision and development of implementation instruments (e.g., promotion, accreditation) will be necessary to (1) identify local and regional variations and barriers in the implementation process, and to (2) develop indicators and tailored tools suited for improving implementation. A close cooperation of ESA institutions with industry partners, research institutions, and other interested organisations and individuals is necessary to achieve this goal – and to ‘walk the talk’.
During Euroanaesthesia 2017 in Geneva, Switzerland, a session will be dedicated to the current state of the implementation process, and to the PSQC project to assess and improve practice implementation of the HD: ‘Following up the Helsinki Declaration on Patient Safety in anaesthesiology’ (Symposium 16SF, Room E, Saturday, 3 June 2017, 14:00–15:30).