For more than ten years, the Society of Cardiovascular Anesthesiologists (SCA) has realized the need to make quality and safety a priority. Dr. Atilio Barbeito, Department of Anesthesiology, Duke University Medical Center, Veterans Affairs Medical Center, Durham, North Carolina, and colleagues from throughout the United States describe the SCA’s 10-year effort to improve patient safety in cardiac ORs in the article titled “FOCUS: The Society of Cardiovascular Anesthesiologists’ Initiative to Improve Quality and Safety in the Cardiovascular Operating Room,” published in this month’s issue of Anesthesia & Analgesia.
FOCUS stands for Flawless Operative Cardiovascular Unified Systems, a somewhat unwieldy program acronym designed to call out principles of human factors engineering. Over the past decade FOCUS has spawned a number of observational studies of hazards and errors using such tools as a systematic review of the literature, a detailed sifting of incidents in the United Kingdom National Reporting and Learning System (NRLS), and direct observation of cardiac surgical cases in multiple different institutions. This work has identified numerous hazards in the OR including poor design of facilities and equipment, poor teamwork, and failure to adhere to best practices.
While the ultimate goal of FOCUS is to improve patient outcomes, not one of the 10 descriptive papers now published from this project can document that improvement has actually occurred. The FOCUS projects have identified numerous hazards, classified them under several different taxonomies, and done their best to publish and educate. Nevertheless, as the authors admit, cardiac surgery is an extremely complicated system and OR culture can be difficult to change without the buy-in of all participants. For example, the FOCUS authors note that their group has never included official representation from the cardiac surgeons. Further, true adverse outcomes are generally rare in anesthesia, making it difficult for prospective research studies to achieve sufficient statistical power. Also, physicians in general – and cardiologists, surgeons, and cardiovascular anesthesiologists in particular – have a tendency to “reinvest” gains in safety by operating on sicker patients. Survival thus remains relatively constant unless it is examined through the lens of precise risk adjustment. These issues notwithstanding, it is clear that FOCUS is on the right track both in terms of how it is being conducted and in what it will ultimately achieve.