Reader response
Myron Yaster MD
Because of space and time considerations (PAADs need to be 5-6 minute reads), I wasn’t able to include all of the comments from the authors of the recent PAAD “Supporting Safer Surgery: System-Level Interventions to Enhance Pediatric Perioperative Safety”.here Here are some of their comments as well as some of your own:
From Joseph Cravero MD, Boston Children’s Hospital
The authors of this article describe a fundamental change in culture of their organization. The concepts enumerated in the report are not unique or particularly original, many leaders involved in Pediatric Anesthesia have embarked on similar change-management endeavors. Having noted this, culture change is probably the most difficult challenge for leaders of any organization, and the cohort at Lurie Children’s deserve immense credit for taking this on so seriously and (apparently) accomplishing a fundamental change in the manner in which safety is approached in their organization. Remarkably, there appears to be “buy in” from all levels of leadership in their enterprise, a truly unusual confluence of purpose. Moving forward it will be fascinating to see if improvement at one (or more) institution(s) leads to pressure for change elsewhere. One could point to the advent of high reliability systems in the Japanese automobile industry that led to significant improvements in process and outcomes (famously at Toyota). Their focus on Site Reliability Engineering, Root Cause Analysis, and “blameless culture” ultimately were so successful they were adopted at other corporations as a requirement to remain competitive. Health Care Organization have been relatively late to this party, but reports (such as this) should encourage all of us that the well-proven concepts that create High Reliability Organizations can directly improve Pediatric Anesthesia practice and we should all share in our experiences and successful applications
From Timothy W. Martin, MD, MBA, FASA, FAAP, Professor of Anesthesiology and Pediatrics, Associate Chair for Education, Anesthesiology Residency Program Director, Chief, Division of Pediatric Anesthesia, University of Florida (UF) College of Medicine
The one rather technical question that stood out to me after reading the article from Pediatrics is the possible disconnect between the paper’s cited “cluster of 13 safety events” as shown in the background section of the abstract, and the paper’s table 1 that lists fourteen (14) events. This confused (and distracted) me a bit, and I wonder if it may likewise confuse some PAAD readers who take time to look up the original article?
Beyond Dr. Cravero’s commentary, all I can offer as an added “obstacle” or challenge to some of the accepted HRO principles is what some (perhaps many or all) of us who practice in a mixed pediatric and adult perioperative environment (as I do) encounter when we attempt to “standardize” or “implement a common national practice” that somehow runs contrary or at variance from standard adult perioperative practices. I have seen that the “adult standards” or “adult practices” tend to prevail for all patients in the name of standardization and consistency, even if contrary to what we as pediatric anesthesiologists and surgeons may believe is the most appropriate practice for children. A couple of examples I can provide are the demand to stick to a mandatory minimum 2- hour clear liquid fast (really ends up typically being much longer as we all know) because of a reluctance to “muddy waters” and “confuse adult patients, physicians, and providers” and the insistence that all patients remain awake in the OR until the attending surgeon/proceduralist has arrived to conduct the preinduction “briefing”/time-out so that the patient has the opportunity to participate in the ID verification and ask any questions—obviously inapplicable to young pediatric patients and infants, and potentially dangerous in some cases. And there are other examples.
Dr. Randy Flick MD, Mayo Clinic
I want to reiterate and simplify some key points from the PAAD
High Reliability Organizations (HROs) operate in high-risk settings while maintaining very low harm rates by emphasizing system failure over individual blame, preoccupation with failure, deference to expertise, reluctance to simplify, commitment to resilience, and standardized communication. SSEs are events that reach patients and cause moderate to severe harm or death; sentinel events signal death, severe harm, permanent harm, or other events requiring immediate investigation. This distinction matters because the response must move beyond case review to organizational redesign, with clear ownership for preventing recurrence.
System diagnosis and key drivers. Root-cause analyses identified recurring problems: communication breakdowns, inconsistent leadership responses, retained foreign bodies, wrong-site or wrong procedure events, incorrect line placement, operating-room fires, and workflow defects. The key driver diagram organized improvement into three domains: leadership, culture of safety, and data systems. This framing is important: the intervention did not rely on one training module or checklist, but on a linked package of leadership visibility, shared language, feedback, coaching, and transparent event analysis.
Interventions. Three interventions were introduced over six months. First, perioperative surgical safety stand-downs temporarily paused elective surgical work so multidisciplinary teams could hear executive leaders review safety data, expectations, and recent events. Families also described the human consequences of medical error, reinforcing patient-centered accountability. Second, staff completed error-prevention training using the Partnering on S.A.F.E. Care tools: ARCC to speak up, QVV to question and verify, STAR to pause during high-risk tasks, and SBAR to standardize communication. These tools were reinforced through modules, badge cards, digital signage, meetings, and daily safety briefings. Third, a multidisciplinary safety coach program supported peer-to-peer coaching, simulation, appreciative inquiry, real-time feedback, and reporting of near misses and good catches. A Just Culture algorithm helped leaders distinguish system defects, human error, and risky choices while preserving accountability and learning
For pediatric anesthesiology and perioperative leadership, the practical message is clear: safer surgery requires more than vigilance at the bedside. It requires an engineered culture in which teams can speak up, leaders respond reliably, data are visible, and improvement is continuous. The intervention package also underscores the value of pairing technical safeguards with behavioral reliability: checklists and algorithms help only when teams are trained, psychologically safe, and supported by leaders who act on the information they receive.
From Kyle Joseph Kramer DDS MS
I had to write to you as I just could not believe NO ONE mentioned Horace Wells in the list of self-experimenters. Being an anesthesia-centric group I would have sworn someone would have pointed out that Wells underwent nitrous oxide anesthesia himself and had a tooth removed, reporting that he felt “just a prick” and setting off the wildfire discovery of general anesthesia following Morton’s ether demonstration. Much has been written about who should get credit and for what; however, Wells is undoubtedly one of the grandfathers of anesthesia.
From Paul G. Firtth, MBCHB
I am surprised you did not mention one of the biggest and most important examples of self-experimentation of all: Horace Wells’ self-experiment with nitrous oxide, which led to the discovery of anesthesia. Dentist Wells observed that a volunteer at a nitrous oxide demonstration, Samuel Cooley, did not experience pain when he injured his leg while intoxicated with nitrous. Wells asked the organizer, Gardner Colton, to administer nitrous oxide to him the next day, while his colleague John Riggs pulled Well’s diseased molar tooth. The successful analgesia on December 11th led Wells to start using nitrous oxide.
Well’s former student and sometime dentistry partner, William Morton, was inspired to introduce the practice in Boston. At Wells’ suggestion, Morton went to Boston chemist Charles Jackson for guidance. Jackson had previously tried inhaled ether as a pulmonary soothing agent - and based on his experience with self-experimentation, he suggested Morton try ether. Morton tried ether successfully in his dental practice on September 30th, then experimented with a series of surgical patients at the Massachusetts General Hospital - and the rest is history.
And that’s not even talking about the subsequent discovery of pediatric anesthesia! The discovery of anesthesia was second only to the discovery of vaccination as the most important medical revolution in history. It is very interesting to see the parallels with the work of Boylston, Jenner , and Salk.