We all were introduced during residency to patient safety in various ways, often through the efforts of the Anesthesia Patient Safety Foundation. The first intro-duction to system safety after residency (Dr. Arron) came when a senior clinician in charge of our “quality” committee noticed a rash of epidural blood patches in thoracic and obstetric patients. They were linked to two clinicians who preferred one brand of epidural kits. Other department members used different kits since they judged the other epidural catheters too stiff and difficult to pass. When the epidural kits with the stiff catheter were removed from the hospital, the post-dural puncture headache (PDPH) incidence again became a rare event. By including the technology into his evaluation of clinical performance and adverse outcomes, he identified the likely problem, prevented future adverse events and improved the performance of the...

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