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Birnbach, David J. MD, MPH; Brull, Sorin J. MD, FCARCSI (Hon.); Prielipp, Richard C. MD, MBA, FCCM

doi: 10.1213/ANE.0000000000001423
Letters to the Editor: Letter to the Editor

University of Miami Miller School of Medicine, Miami, Florida,

Department of Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, Florida

University of Minnesota Medical School, Minneapolis, Minnesota

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J'agis: A Slow Start That’s Finally Showing Some Progress: Now It’s Time to Work Together to Make Change Happen

We thank the authors1 for their response to our editorial2 and for the important work that they, the National Health Service, the World Federation of Societies of Anaesthesiologists, and numerous other organizations and groups have been doing in this important patient safety area. While we applaud the actions that are being taken by the international anesthesia community to attempt to deal with the very real problem of epidural/spinal catheter misconnects, we still wonder why there has not been a faster and more orchestrated effort on the part of the anesthesia community, why all the involved parties in the United States have not been more active, and why it has taken this long to get to a point where we can somewhat optimistically say that a solution is in sight. We are still surprised that, except for California, there has been so little overt effort to solve this problem in the United States. In many ways, Gelb et al1 amplify our point when they state that efforts were initiated in Europe in 1999 (ie, the same year that the Euro currency was introduced, the Mars Polar Lander was launched, and the war in Kosovo ended when Yugoslavia and the North Atlantic Treaty Organization signed a peace treaty) and that attempts in the United Kingdom between 2009 and 2015 largely failed because of concerns about proprietary designs, limited clinical acceptability, and impending publication of ISO 80369. An editorial published in this journal 4 years ago3 warning of the risks to patients did not appear to prompt any definitive action in the United States. Is this really a problem that needed 17 years to get to the point where we will have a safer option in a year or 2? There is no doubt that pockets of activity have occurred in an effort to address this issue, but we continue to believe what we originally stated in our editorial. “We, as a community, and as a profession (have not and) are not doing enough.” We encourage the Anesthesia Patient Safety Foundation to lead the charge to bring efforts in the United States up to speed with international activity.

Gelb et al have stated that the “accusations that the entire anesthesia community has turned a blind eye” is wrong. They are correct literally, but they misread our intent. We were challenging the practitioners, manufacturers, state and federal agencies, and national organizations in the United States to act on behalf of patient safety. It is a metaphor to say that the entire anesthesia community has turned a blind eye to this situation, but we continue to believe that the “fix” has been too long in the making and that complacency, bureaucratic issues, and politics have prevented an appropriately speedy resolution to a practice that has caused unnecessary harm to patients. Innumerable case reports document our past failings.2 The lessons learned from the delays in reaching a successful solution in this situation should be fully understood to learn from this experience so that the entire anesthesia community, including those in the United States, can commit to swifter action the next time a patient hazard associated with our routine work is identified.

Ultimately, we believe that our main goal of bringing the problem of spinal/epidural catheter misconnection to the forefront of thoughtful discussion has been realized. It is likely that many clinicians are now more aware of the potential catastrophic complications after reading these letters and will act before this tragedy happens to their own patients. The French expression J’agis means, “I take action.” We will rest much easier when the “I” turns to “We” and when anesthesia practitioners, societies, governmental agencies, foundations, and industry can work together in a timely and efficient manner to prevent patient harm.

David J. Birnbach, MD, MPHUniversity of Miami Miller School of MedicineMiami,

Sorin J. Brull, MD, FCARCSI (Hon.)Department of AnesthesiologyMayo Clinic College of MedicineJacksonville, Florida

Richard C. Prielipp, MD, MBA, FCCMUniversity of Minnesota Medical SchoolMinneapolis, Minnesota

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1. Gelb AW, Mainland P, Phillips P, et al. J’agis. Anesth Analg. 2016;123:798799.
2. Birnbach DJ, Brull SJ, Prielipp RC. J’Accuse! Failure to prevent epidural and spinal catheter misconnections. A A Case Rep. 2016;6:107110.
3. Birnbach DJ, Vincent CA. A matter of conscience: a call to action for system improvements involving epidural and spinal catheters. Anesth Analg. 2012;114:494496.
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