RT Book, Section A1 Butterworth IV, John F. A1 Mackey, David C. A1 Wasnick, John D. SR Print(0) ID 1161434361 T1 Safety, Quality, & Performance Improvement T2 Morgan & Mikhail's Clinical Anesthesiology, 6e YR 2018 FD 2018 PB McGraw-Hill Education PP New York, NY SN 9781259834424 LK accessanesthesiology.mhmedical.com/content.aspx?aid=1161434361 RD 2024/10/04 AB KEY CONCEPTS In the 1980s, anesthesiology was recognized as the first medical specialty to adopt mandatory safety-related clinical practice guidelines. Adoption of these guidelines, describing standards for basic monitoring during general anesthesia, was associated with a reduction in the number of patients suffering brain damage or death secondary to ventilation mishaps during general anesthesia. In 1999 the Institute of Medicine of the (U.S.) National Academy of Sciences summarized available safety information in its report, To Err Is Human: Building a Safer Healthcare System, which highlighted many opportunities for improved quality and safety. It has long been recognized that quality and safety are closely related to consistency and reduction in practice variation. In manufacturing and in medicine, there is a natural tendency to assume that errors can be prevented by better education or better management of individual workers (ie, to look at errors as individual failures made by individual workers rather than as failures of a system or a process). To reduce errors, one changes the system or process to reduce unwanted variation so that random errors are less likely.