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Q UA L I T Y A N D S A F E T Y
IN ANESTHESIA AND
P E R I O P E R AT I V E C A R E
Q UA L I T Y A N D S A F E T Y
IN ANESTHESIA AND
P E R I O P E R AT I V E C A R E

EDITED BY

K E I T H J. RU S K I N, M D
Professor of Anesthesia and Critical Care
University of Chicago
Chicago, Illinois

M A R JO R I E P. S T I E G L E R , M D
Associate Professor of Anesthesiology
University of North Carolina
Chapel Hill, North Carolina

S TA N L E Y H . RO S E N B AU M , M D
Professor of Anesthesiology, Medicine, and Surgery
Yale University School of Medicine
New Haven, Connecticut

1
1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press

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© Oxford University Press 2016

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
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rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

Library of Congress Cataloging-​in-​Publication Data

Names: Ruskin, Keith., editor. | Stiegler, Marjorie P., editor. | Rosenbaum, Stanley H., editor.
Title: Quality and safety in anesthesia and perioperative care /
edited by Keith J. Ruskin, Marjorie P. Stiegler, Stanley H. Rosenbaum.
Description: Oxford ; New York : Oxford University Press, [2016] |
Includes bibliographical references and index.
Identifiers: LCCN 2016006863 (print) | LCCN 2016007645 (ebook) | ISBN 9780199366149 (alk. paper) |
ISBN 9780199366156 (e-book) | ISBN 9780199366163 (e-book) | ISBN 9780199366170 (online)
Subjects: | MESH: Medical Errors—prevention & control | Patient Safety—standards |
Anesthesiology—standards | Perioperative Care—standards | Patient Care Team—standards
Classification: LCC RD82 (print) | LCC RD82 (ebook) | NLM WX 153 | DDC 617.9/60289—dc23
LC record available at http://lccn.loc.gov/2016006863

This material is not intended to be, and should not be considered, a substitute for medical or
other professional advice. Treatment for the conditions described in this material is highly
dependent on the individual circumstances. And, while this material is designed to offer
accurate information with respect to the subject matter covered and to be current as of the
time it was written, research and knowledge about medical and health issues are constantly
evolving and dose schedules for medications are being revised continually, with new side
effects recognized and accounted for regularly. Readers must therefore always check the
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Printed by WebCom, Inc., Canada
In memory of Lloyd Leon Ruskin

‫הכרבל ונורכיז‬
CONTENTS

Foreword ix PART II: Clinical Applications

Preface xiii
9. Adverse Event Prevention
Acknowledgments xv
and Management 131
Contributors xvii
Patrick J. Guffey
and Martin Culwick
PART I: Scientific Foundations 10. Complex Systems and Approaches
1. Patient Safety: A Brief History 3 to Quality Improvement 143

Robert K. Stoelting Loren Riskin and Alex Macario

2. Cognitive Load Theory 11. Crisis Resource Management and

and Patient Safety 16 Patient Safety in Anesthesia Practice 158

Elizabeth Harry Amanda R. Burden,

and John Sweller Jeffrey B. Cooper,
and David M. Gaba
3. Errors and Violations 22
12. Quality in Medical Education 167
Alan F. Merry
Viji Kurup
4. The Human-╉Technology Interface 48
13. Regulating Quality 174
Frank A. Drews
and Jonathan R. Zadra Robert S. Lagasse

5. Deliberate Practice and 14. Creating a Quality

the Acquisition of Expertise 66 Management Program 189

Keith Baker Richard P. Dutton

6. Fatigue 80 15. Health Information Technology

Use for Quality Assurance
Michael Keane
and Improvement 200
7. Situation Awareness 98 Christine A. Doyle
Christian M. Schulz
16. Safety in Remote Locations 213
8. Creating a Culture of Safety 114 Samuel Grodofsky, Meghan
Thomas R. Chidester Lane-╉Fall, and Mark S. Weiss
viii Contents

17. Medication Safety 228 20. Managing Adverse Events:

Alan F. Merry The Aftermath and the Second
Victim Effect 269
18. Operating Room Fires
Sven Staender
and Electrical Safety 242
Stephan Cohn Index 275
and P. AlLan Klock, Jr.
19. Disruptive Behavior: The Imperative
for Awareness and Action 254
Sheri A. Keitz and David J. Birnbach
F O R E WO R D
Although safety issues confront many indus-
tries, the most complex challenges—​by far—​
lie in patient safety. As Lewis Thomas1 pointed
out, nineteenth-​century physicians could in-
fluence the outcome of illness only modestly at
best. Advances in medical science and technol-
ogy now enable extraordinary interventions
that can dramatically improve patients’ lives.
On the other hand, highly specialized proce-
dures that are designed to intervene precisely
in intricate physiological processes are inher-
ently vulnerable to adverse events and are ter-
ribly unforgiving of errors. Moreover, patients
who seek medical care often have multiple dis-
ease processes, further increasing their vul-
nerability to mishap.
Modern healthcare systems are extremely
complex, involving many individual profes-
sionals with different kinds of expertise who
must work together as teams. Diverse organ-
izational factors influence how effectively in-
dividuals and teams are able to do their work.
Every action in the extended healthcare proc-
ess provides opportunities for things to go
wrong, adversely affecting patient outcome.
By the time the Institute of Medicine’s 1999
report, To Err Is Human,2 galvanized public
awareness of the extent of iatrogenic harm, an-
esthesiologists had already established them-
selves as leaders in the medical community’s
search for ways to improve patient safety.
As part of that search, the medical com-
munity has examined ways in which other
industries have improved their safety, and this
has led to collaboration with the human factors
community. Human factors is an applied dis-
cipline that draws upon the cognitive, social,
physiological, and engineering sciences to
understand the conditions that affect human
performance and to devise ways to enhance
and protect that performance. Medical safety
researchers have particularly drawn on the
contributions that human factors science has
made to commercial aviation safety, through
concepts such as situation awareness, crew
resource management, threat and error man-
agement, high-​ reliability organizations, and
safety culture. Procedures such as checklists
and explicit practices for data monitoring have
also emerged from aviation, as have principles
for designing equipment interfaces such as
the visual displays in modern airline cockpits
that help pilots maintain situation awareness.
These concepts, procedures, and design prin-
ciples can be adapted to improve patient safety.
Human factors science has also improved
safety in many industries by chipping away at
long-​standing but misleading concepts of the
nature of the errors made by expert profession-
als. For many years, it was assumed that if a
well-​trained professional could normally per-
form some task without difficulty, then errors
in the performance of that task in an accident
sequence must be the “cause” of that accident.
This philosophy implies that the professional
who made the error is deficient in some way.
But in reality, accidents almost always involve
the confluence of many factors, and the in-
teraction of those factors is partly a matter of
chance. Errors are only part of this confluence,
x Foreword
and indeed are themselves consequences of
other underlying causes. Unfortunately, in-
vestigators have too often lacked normative
data on routine operations in which no acci-
dent occurred—​data that sometimes show the
same errors and procedural deviations taking
place fairly frequently, but without producing
mishap. Without this normative data, it is all
too easy to draw simplistic conclusions about
the causes of error and the interacting roles of
many factors in accident sequences.
In recent years a more sophisticated under-
standing of both errors and accident causality
has emerged. It is now generally accepted that
any errors made by human operators should
be used as a starting point of an accident in-
vestigation, not the endpoint. Errors made by
skilled experts (as opposed to novices) are not
root causes in themselves, but rather manifes-
tations of the flaws and inherent limitations
of the overall sociotechnical system in which
these experts work.
The causes of experts’ errors are intimately
related to the cognitive mechanisms that enable
experts to skillfully perform tasks that do not
allow 100% reliability. Both correct and incor-
rect performance must be understood in the
context of the experience, training, and goals
of the individual; the characteristics of the tasks
performed; human-​ machine interfaces; both
routine and unanticipated events; interactions
with other humans in the system; and organi-
zational aspects. These aspects include both
the explicit and implicit manifestations of the
organization’s culture and goals, the inherent
tensions between safety and production, and in-
stitutional reward structures, policies and pro-
cedures. Organizations whose leaders formally
endorse high safety practices all too often fail to
realize that their reward structure encourages
individuals to take actions that are unsafe.
As the authors of several chapters in this
book point out, iatrogenic error is only one
of many issues that affect patient outcome.
Practices that reduce vulnerability to error
and enable trapping of errors before harm is
done allow medical practitioners and institu-
tions to identify and correct broader systemic
problems that lead to the errors that cause
harm. Further, these practices can also help
identify factors affecting patient outcome, even
when professional error is not involved. For ex-
ample, incident-​reporting systems can identify
systemic issues such as the lack of timely avail-
ability of critical resources for dealing with
emergencies in operating rooms.
Although concepts and practices from do-
mains such as aviation can be brought to bear
in medicine to good effect, simply importing
these concepts and practices and plopping them
down in medical settings will not be effective
and may cause harm. Any intervention must be
tuned to the specific setting. For example, avia-
tion checklists, which have saved many lives,
are integrated into the flow of cockpit tasks in
ways that do not distract the pilots or interfere
with performing other essential duties. This
integration did not happen overnight; it is an
ongoing process still being refined and tailored
to the needs of individual airlines. The value of
checklists in medical practice has been estab-
lished,3 but considerable work is still required
to design their content and integrate their use
into settings such as operating rooms in ways
that are easy to use and that do not impose ad-
ditional cognitive workload on practitioners.
Introducing new concepts into medical
practice requires expert analysis of the spe-
cific settings in which they are to be used, in-
cluding the flow of tasks among members of
the team, the information each team member
has and needs, the roles and responsibilities of
each team member, the level of workload, the
arrangement of equipment, and the culture in
which the team works. This analysis is best ac-
complished through extensive collaboration
between medical professionals and human fac-
tors experts. The chapters of this book illustrate
the benefits of this kind of collaboration. The
authors, all leading experts in their respective
fields, have worked across disciplinary lines to
good effect. Anesthesiologists with extensive
expertise in patient safety demonstrate a thor-
ough understanding of human factors issues,
and the chapters by human factors experts
show solid understanding of the medical issues.

When human factors concepts such as crew
resource management were introduced to the
aviation industry in the early 1980s, not all par-
ties welcomed the changes. Many senior airline
captains felt threatened and worried that their
command authority would be undermined.
Acceptance was gradual, but was consistently
supported by airline management and regula-
tory authorities, and over time pilots learned
that these concepts could help them avoid
errors and make good decisions. The concepts
continue to evolve, but today few in the airline
industry question the value of these concepts
when applied appropriately.
A similar situation exists today in medicine—​
not all medical practitioners are enthusiastic
about the pathways suggested in this book. (An
entire field of study, implementation science, has
sprung up to address cultural, economic, and
management bottlenecks impeding implemen-
tation of healthcare improvements.)
This book offers clearly written chapters
based on accepted safety, human perfor-
mance, and quality management science that
will help to ameliorate this resistance. Beyond
that, we must understand that cultural change
is almost always difficult and slow. Regulatory
and organizational support is of course cru-
cial, but in the long run, the effectiveness of
the changes proposed in this book will de-
termine acceptance. Business managers who
foreword xi
discover a long-​term cost benefit will become
advocates, as will senior surgeons and anes-
thesiologists who avoid a mishap because a
team member was empowered to speak up. In
spite of sometimes conflicting pressures, every
healthcare professional wants to improve pa-
tient outcome.
This book lays a solid scientific foundation
for understanding the challenges that must
be addressed to substantially improve patient
safety and outcome. It also provides explicit
guidance on practical ways to initiate reform
at all levels, from operating room practices to
institutional procedures. Although the book fo-
cuses on anesthesiology and perioperative care,
it provides a foundation that can be a model for
all areas of medicine.
REFERENCES
1. Thomas L. The Medusa and the Snail: More
Notes of a Biology Watcher. New York: Viking
Press; 1974.
2. Institute of Medicine. To Err Is Human: Building
a Safer Health System. Washington, DC: National
Academy Press; 1999.
3. Gawande A. The Checklist Manifesto. New York:
Metropolitan Books; 2010.
R. Key Dismukes, PhD
Chief Scientist for Aerospace
Human Factors (Retired)
NASA Ames Research Center
Moffett Field, California
P R E FAC E
Perioperative medicine is characterized by
many factors that can cause patient harm.
Care is delivered by multispecialty teams with
varying levels of expertise and mutual famil-
iarity, while patients present in various states
of preexisting health and optimization for
procedures that impart significant physiologic
stresses and surgical insults. Patient care in
this environment requires a high level of co-
ordination and communication among team
members, management of large quantities
of information, and effective interfaces be-
tween humans and sophisticated technology.
Hundreds of thousands of adverse events and
near misses occur throughout the United States
annually. At any time, one or more factors, in-
cluding patient illness, the surgical procedure,
team dynamics and communication, or equip-
ment malfunction, may combine to cause a
life-​threatening condition. Creating a safe en-
vironment requires a coordinated strategy that
reduces the number of errors while simulta-
neously decreasing the harm that an error can
cause. As part of this, conditions that foster or
allow error must be minimized, while systems
for earlier identification and rescue from errors
must be robust.
Anesthesiologists were among the first to
recognize that teamwork training, safety cul-
ture, and quality management were essential
components of clinical care, and Quality and
Safety in Anesthesia and Perioperative Care
expands on this knowledge. Chapters in this
book emphasize strategies that can be used in
community practice as well as major academic
medical centers. Part I of the book provides
an overview of the scientific foundations of
human factors science. Chapters in this sec-
tion explore causes of errors and violations,
threat and error management, team training,
and the essentials of a culture of safety. Part II
offers practical organizational suggestions for
improving quality of care and patient safety
in the perioperative setting and for the grow-
ing number of procedures that take place in
remote locations, including change manage-
ment, quality measurement, safety regulation,
optimizing team and technology interactions,
and managing clinicians who are disruptive or
impaired, whether by fatigue, substance abuse,
or the aftermath of an adverse event. Chapters
are concisely written, with illustrations that
highlight key points.
Quality and Safety in Anesthesia and Peri-
operative Care offers a depth of informa-
tion on this topic that cannot be found in a
single chapter in an anesthesiology textbook.
Although this book was written primarily for
anesthesia clinicians, fellows, and residents,
nearly all of the content is applicable to oper-
ating room personnel, hospital administrators,
and medical risk managers. The book provides
critical information for the anesthesiologist in
academic or private practice, as well as physi-
cians who manage a training program and are
looking for a structured method of teaching
safety and quality. Physician executives can
also use this book to guide quality and safety
programs throughout a healthcare institution.
Indeed, the content of this text is applicable to
xiv Preface

any healthcare setting or discipline, because Keith J. Ruskin, MD

the concepts of error prevention, risk mitiga- Marjorie P. Stiegler, MD
tion, safety culture, and quality improvement Stanley H. Rosenbaum, MD
are the same. It is our sincere hope that readers
of this book will be better equipped to improve
patient outcomes.
AC K N O W L E D G M E N T S
Successfully completing a project of this mag-
nitude is impossible without the support of
many people. The editors would first like to
thank Rebecca Suzan and Andrea Knobloch
for their insights and guidance. We would like
to thank our chapter authors, who provided
well-​
w ritten, highly informative chapters
and kept us on schedule. We thank the many
residents and faculty of our respective institu-
tions, who read and commented on the manu-
script. Most important, we thank our families
for their constant support and encourage-
ment. Keith J. Ruskin would like to thank
Anna Ruskin, MD, and Daniel Ruskin, and
dedicates the book to the memory of his father,
Lloyd Leon Ruskin. Marjorie P. Stiegler would
like to thank James Stiegler for his unwaver-
ing support, and Henry and Juliet Stiegler for
their resilience. Stanley H. Rosenbaum would
like to thank Judith and Adina Rosenbaum for
their loving support, and always treasures the
memory of Paula E. Hyman.
C O N T R I BU T O R S

Keith Baker, MD, PhD Jeffrey B. Cooper, PhD

Associate Professor of Anaesthesia Professor of Anesthesia
Harvard Medical School Harvard Medical School
Massachusetts General Hospital Executive Director, Center for Medical
Boston, Massachusetts Simulation
Massachusetts General Hospital
David J. Birnbach, MD, MPH
Boston, Massachusetts
Miller Professor and Vice Provost
Senior Associate Dean for Quality, Martin Culwick, MB, ChB, BSc,
Safety, and Risk FANZCA, MIT
Director, UM-​JMH Center for Patient Safety Medical Director
University of Miami Miller School of Australian and New Zealand Tripartite
Medicine Anaesthetic Data Committee
Miami, Florida Senior Specialist
Royal Brisbane and Women’s Hospital
Amanda R. Burden, MD
Brisbane, Australia
Associate Professor of Anesthesiology
Director Clinical Skills and Simulation Christine A. Doyle, MD
Cooper Medical School of Rowan Anesthesiology Partner, CEP America
University San Jose, California
Cooper University Hospital
Camden, New Jersey Frank A. Drews, PhD
Professor Cognitive Psychology
Thomas R. Chidester, PhD Director of the Human Factors
Federal Aviation Administration Certificate Program
Civil Aerospace Medical Institute Department of Psychology
Oklahoma City, Oklahoma University of Utah
Stephan Cohn, MD Salt Lake City, Utah
Assistant Professor of Anesthesia
and Critical Care
University of Chicago
Chicago, Illinois
xviii Contributors

Richard P. Dutton, MD, MBA Viji Kurup, MD

Chief Quality Officer
US Anesthesia Partners
Anesthesiologist, Baylor University
Medical Center
Dallas, Texas
David M. Gaba, MD
Professor of Anesthesiology,
Perioperative and Pain Medicine
Stanford University School of Medicine
Stanford, California
Samuel Grodofsky, MD
Department of Anesthesiology
and Critical Care
The Hospital of the University
of Pennsylvania
Philadelphia, Pennsylvania
Patrick J. Guffey, MD
Assistant Professor of Anesthesiology
University of Colorado
Children’s Hospital Colorado
Aurora, Colorado
Elizabeth Harry, MD
Instructor in Medicine
Harvard Medical School
Brigham and Women’s Hospital
Boston, Massachusetts
Michael Keane, BMBS FANZCA
Adjunct Associate Professor
Centre for Human Psychopharmacology
Swinburne University
Adjunct Lecturer in Public Health
Monash University
Melbourne, Australia
Sheri A. Keitz, MD, PhD
Chief, Division General Internal Medicine
Vice Chair for Clinical Affairs Department
of Medicine
UMass Memorial Health Care
University of Massachusetts Medical School
Worcester, Massachusetts
P. Allan Klock, Jr., MD
Professor of Anesthesia and Critical Care
University of Chicago
Chicago, Illinois
Associate Professor of Anesthesiology
Yale University School of Medicine
New Haven, Connecticut
Robert S. Lagasse, MD
Professor and Vice Chair, Quality
Management and Regulatory Affairs
Department of Anesthesiology
Yale University School of Medicine
New Haven, Connecticut
Meghan Lane-​Fall, MD, MSHP
Assistant Professor of Anesthesiology
and Critical Care
The Hospital of the University of Pennsylvania
Perelman School of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania
Alex Macario, MD, MBA
Professor of Anesthesiology, Perioperative
and Pain Medicine
Stanford University Medical Center
Stanford, California
Alan F. Merry, FANZCA, FFPMANZCA,
FRCA, FRSNZ
Professor and Head of School of Medicine
The University of Auckland
Specialist Anesthesiologist
Auckland City Hospital
Auckland, New Zealand
Michael J. Murray, MD, PhD
Professor of Anesthesiology
Mayo Clinic
Phoenix, Arizona
Loren Riskin, MD
Clinical Instructor in Anesthesiology,
Perioperative and Pain Medicine
Stanford University School of Medicine
Stanford, California
Christian M. Schulz, MD
Department of Anesthesiology
Klinikum rechts der Isar
Technische Universität München
Munich, Germany
 contributors xix

Sven Staender, MD Mark S. Weiss, MD

Past-Chairman ESA Patient Safety & Quality Assistant Professor of Clinical
Committee Anesthesiology and Critical Care
Vice-Chairman European Patient Safety The Hospital of the University
Foundation of Pennsylvania
Department of Anesthesia and Intensive Perelman School of Medicine
Care Medicine University of Pennsylvania
Regional Hospital Philadelphia, Pennsylvania
Männedorf, Switzerland
Jonathan R. Zadra, PhD
Robert K. Stoelting, MD Adjunct Assistant Professor of Psychology
President, Anesthesia Patient Safety University of Utah
Foundation Salt Lake City, Utah
Emeritus Professor of Anesthesia
Indiana University School of Medicine
Indianapolis, Indiana
John Sweller, PhD
Emeritus Professor of Educational Psychology
School of Education
University of New South Wales
Sydney, Australia
PART I

Scientific Foundations
1
Patient Safety
A Brief History
R O B E R T K . S T O E LT I N G
INTRODUCTION
Patient safety is a new and distinct healthcare
discipline that emphasizes the reporting, anal-
ysis, and prevention of medical error that often
leads to adverse healthcare events.1,2
Hippocrates recognized the potential for in-
juries that arise from the well-╉intentioned actions
of healers. Greek healers in the fourth century
bce drafted the Hippocratic Oath and pledged to
“prescribe regimens for the good of my patients
according to my ability and my judgment and
never do harm to anyone.” Since then, the direc-
tive primum non nocere (“first do no harm”) has
become a central tenet of contemporary medicine.
However, despite an increasing emphasis on the
scientific basis of medical practice in Europe and
the United States in the late nineteenth century,
data on adverse outcomes were hard to come by,
and the various studies commissioned collected
mostly anecdotal events.2
The modern history of patient safety can
be traced to the late 1970s and early 1980s
and reflects initially the activities of the
American medical specialty of anesthesiol-
ogy.3 Anesthesiology, via its professional soci-
ety, the American Society of Anesthesiologists
(ASA), was the first medical specialty to cham-
pion patient safety as a specific focus.4 An early
driving force to address the causes of anesthe-
sia accidents was the spiraling cost of profes-
sional liability insurance for anesthesiologists.
Anesthesiologists constituted 3% of physicians
and generated 3% of malpractice claims, but
those claims accounted for a disproportion-
ately high 12% of medical liability insurance
payout. The relationship of patient safety to
malpractice insurance premiums was easy
to predict: if patients were not injured, they
would not sue, the payouts would be reduced,
and insurance rates would follow.
The creation of the ASA Committee on
Patient Safety and Risk Management in 1983
represented the first time a professional medi-
cal society independently addressed patient
safety as a specific focus, with the goal of de-
termining the cause of anesthetic accidents.4
Subsequently, the formation of the Anesthesia
Patient Safety Foundation (APSF) in 1985
marked the first use of the term patient safety
in the name of a professional reviewing organi-
zation.3–╉8 Likewise, in Australia, the Australian
Patient Safety Foundation was founded in 1989
for anesthesia error monitoring.2
Today, the specialty of anesthesiology is
widely recognized as the pioneering leader in
patient safety efforts. It has been stated that the
“discovery” of anesthesia in the 1840s was a
uniquely American contribution to the world
of medicine. The legitimization and recogni-
tion of patient safety as an important concept
was again a uniquely American contribution to
the world of medicine.
T H E E A R LY H I S T O R Y
OF THE ASA AS A
PIONEER IN SAFETY
Serendipitous Coincidences
As with most important historical develop-
ments, coincidence was prominent in the
4 Scientific Foundations
creation of the APSF.4 Several factors came
together to facilitate the development of an
idea (“vision”) held by Ellison C. Pierce, Jr.,
MD, who was then the chair of anesthesia at
the New England Deaconess Hospital in the
Harvard Medical School system. Dr. Pierce’s
interest in patient safety was originally
stimulated in 1962 when, as a junior faculty
member, he was assigned to give a lecture to
the residents on “anesthesia accidents.” After
that he sustained his interest in this topic,
keeping files, notes, and newspaper clip-
pings regarding adverse anesthesia events
that harmed patients, especially unrecognized
esophageal intubation.
In April 1982 the ABC television program
20/​20 aired a segment entitled “The Deep
Sleep: 6,000 Will Die or Suffer Brain Damage.”9
The segment opened with the statement, “If
you are going to go into anesthesia, you are
going on a long trip and you should not do
it, if you can avoid it in any way. General an-
esthesia is safe most of the time, but there are
dangers from human error, carelessness and a
critical shortage of anesthesiologists. This year,
6,000 patients will die or suffer brain damage.”
Following scenes of patients who had suffered
anesthesia mishaps, the program went on to
FIGURE 1.1: Driving forces behind the creation of the Anesthesia Patient Safety Foundation.
From Eichhorn JH. The APSF at 25: pioneering success in safety, but challenges remain. APSF Newsletter 2010;25:21–​4 4 (http://​
www.apsf.org/​newsletters/​pdf/​summer_ ​2010.pdf). Reproduced with permission of the Anesthesia Patient Safety Foundation.
say, “The people you have just seen are tragic
victims of a danger they never knew existed—​
mistakes in administering anesthesia.” In an-
other example, a patient was left in a coma fol-
lowing the anesthesiologist’s error in turning
off oxygen rather than nitrous oxide at the end
of an anesthetic (Figure 1.1).
This watershed presentation provoked
public concern about the safety of anesthesia.
Dr. Pierce transformed this potential problem
for the specialty into an opportunity to take
positive, proactive measures. Taking advantage
of his position as first vice president of ASA in
October 1983, he convinced the society’s lead-
ers to create the Committee on Patient Safety
and Risk Management.
Another important event was the ground-
breaking research led by Jeffrey B. Cooper,
PhD, a bioengineer in the Department of
Anesthesia at the Massachusetts General
Hospital.10 Dr. Cooper had focused on re-
vealing how human errors were a major and
fundamental cause of preventable anesthesia
accidents. He and his colleagues adopted the
techniques of critical incident analysis, used in
the study of aviation accidents, to study analo-
gous events that were occurring in anesthe-
sia. Based on Cooper’s work, Richard J. Kitz,

MD, then chair of Cooper’s department,
lectured on the topic to the Royal College of
Anesthetists. The esteemed Professor T. Cecil
Gray was in the audience and suggested that
an international meeting be convened to fur-
ther understand and discuss preventable anes-
thesia injuries.
Dr. Kitz brought the idea of an international
meeting on anesthesia safety to Dr. Pierce, who
by this time was president of ASA. The three
collaborated to organize and host in Boston
the International Symposium on Preventable
Anesthesia Mortality and Morbidity. The 50
invited participants expressed enthusiastic
support for some sort of action to make an-
esthesia safer. After the close of the meeting,
a small group stayed behind, and Dr. Pierce
outlined his proposal to create an indepen-
dent foundation dedicated solely to improving
the safety of anesthesia care, with the vision
that “no patient shall be harmed by anesthe-
sia.” When it came to naming the foundation,
Dr. Cooper suggested the “Anesthesia Patient
Safety Foundation.”4
Creation of the Anesthesia Patient
Safety Foundation
The APSF (www.apsf.org) was launched in
late 1985 as an independent (allowing orga-
nizational agility and the freedom to tackle
openly the sensitive issue of anesthesia acci-
dents) nonprofit corporation with the vision
that “no patient shall be harmed by anesthe-
sia” (Figure 1.2). 3–╉8 The APSF “mission” is to
improve continually the safety of patients
during anesthesia care by
• sponsoring investigations that will
provide a better understanding of
preventable anesthetic injuries;
• encouraging programs that will reduce
the number of anesthetic injuries;
• promoting national and international
communication of information and
ideas about the causes and prevention of
anesthetic injuries;
• establishing a complimentary
information newsletter for all anesthesia
professionals.
Patient Safety 5
Initial financial support came from the ASA
and several corporate sponsors. Members of
the APSF Board of Directors represent a broad
spectrum of stakeholders, including anesthesi-
ologists, nurse anesthetists, nurses, manufac-
turers of equipment and drugs, regulators, risk
managers, attorneys, insurers, and engineers.
The APSF is unique in that it brings together all
stakeholders in patient safety under a neutral
umbrella that facilitates open communication
about the sensitive issues of anesthesia acci-
dents. Today, the APSF persists in pursuit of its
mission of zero tolerance for injury to patients.
It serves as a model for pioneering collabora-
tion and commitment of the entire constella-
tion of anesthesia-╉
related professions to the
common goal of patient safety.
Public Recognition
Recognition of the safety efforts and leadership
came to the APSF in the landmark 1999 report
from the Institute of Medicine (IOM) on errors
in medical care.11 The APSF was the only or-
ganization mentioned as one that had made a
demonstrable and positive impact on patient
safety. In 2005, the Wall Street Journal carried
a front-╉page article about the successful efforts
of anesthesiologists, the ASA, and the APSF to
improve patient safety, rather than focusing
specifically on tort reform.12
Culture of Safety
In the long term, the most important contri-
bution of anesthesiology to patient safety may
be the institutionalization and legitimization
of patient safety as a topic of professional con-
cern.3–╉8 In this regard, the creation of the APSF
was a landmark achievement. Unlike profes-
sional societies such as the ASA, the APSF can
bring together many constituencies in health-
care that may well disagree on economic (e.g.,
industry competitors) or political issues, but
that all agree on the goal of patient safety.
ANESTHESIA IS NOW SAFER
It is widely believed that anesthesia is safer
today (at least for healthy patients) than it was
25 to 50 years ago, although the extent of and
reasons for the improvements are debatable.2
FIGURE 1.2: Front page of the March 1986 inaugural issue of the APSF Newsletter. Members of the APSF
Executive Committee, left to right: J. S. Gravenstein, MD; Jeffrey B. Cooper, PhD; E. S. (Rick) Siker, MD (Secretary);
Mr. James E. Holzer; Ellison C (Jeep) Pierce, Jr., MD (President); Mr. Burton A. Dole (Treasurer); and Mr. Dekle
Rountree (Vice President).
From APSF Newsletter 1986;1:1. http://​w ww.apsf.org/​newsletters/​html/​1986/​spring. Reproduced with permission of the Anesthesia
Patient Safety Foundation.

Traditional epidemiological studies on the
incidence of adverse anesthesia events often
cannot be compared because of different
analysis techniques and inconsistent defini-
tions of adverse events. An important result
of this problem is the emergence of inves-
tigative techniques that do not focus on the
incidence of an event but rather on the under-
lying characteristics of mishaps (root cause
analysis) and the attempt to improve subse-
quent patient care so that similar accidents do
not recur. Examples of this approach include
critical incident analysis and the analysis of
closed malpractice claims by the ASA.13 These
approaches analyze only a small proportion
of events that occur, but nevertheless attempt
to extract the maximum amount of valuable
information.
Technological Improvements
In the early 1980s, important advances in tech-
nology became available. Electronic monitoring
(inspired oxygen concentrations, pulse oxim-
etry, capnography) that extended the human
senses facilitated reliable, real-╉time, and con-
tinuous monitoring of oxygen delivery and
patient oxygenation and ventilation. Although
these monitors are believed to improve safety,
no study has demonstrated improved outcomes
from the use of these technologies.
Standards and Guidelines
In the early 1980s, a committee at the Harvard
Hospitals proposed the first standards of prac-
tice for minimum intra-╉ operative monitor-
ing, which became the forerunner of the ASA
Standards for Basic Anesthetic Monitoring
that were adopted in 1986.14,15 Subsequent revi-
sions of the standards have included the addi-
tion of audible alarms on pulse oximetry and
capnography. The intention of standards is to
codify and institutionalize specific practices
that constitute safety monitoring as a strat-
egy to prevent anesthesia accidents. The ASA
is nationally recognized as a leader among
medical specialty societies in the develop-
ment of standards to improve patient safety.
Additional ASA standards and guidelines
(recommendations, consensus statements, and
Patient Safety 7
practice advisories) have been developed. The
American Association of Nurse Anesthetists
(AANA) has also promoted patient safety ef-
forts to its members through the development
and publication of standards.
Closed Claims Project
In the mid-╉1980s, amid professional liability
insurance concerns, the ASA instituted the
Closed Claims Project, which continues today
under the direction of the Anesthesia Quality
Institute (www.aqihq.org) as an ongoing proj-
ect to yield important information through
the study of anesthesia mishaps.13 The Closed
Claims Project is a standardized collection of
malpractice claims against anesthesiologists,
created by the ASA Committee on Professional
Liability. The goal of the Closed Claims Project
is to discover unappreciated patterns of anes-
thesia care that may have contributed to pa-
tient injury and subsequent litigation. This goal
is based on the philosophy that the prevention
of adverse outcomes is the best method for
controlling the costs of professional liability
insurance.
In the late 1980s, analysis of the claims in
the database revealed that respiratory-╉related
events were the most frequently cited source
of anesthesia liability.16 The reviewers also de-
termined that most of these events could have
been prevented if there had been better moni-
toring. These findings compelled the ASA to
develop standards and guidelines relating to
pulse oximetry, capnography, and manage-
ment of the difficult airway.
Safety Research
The APSF awards research grants for proj-
ects that study patient safety–╉related issues.
When the first APSF grants were awarded in
1987, funds for patient safety research in an-
esthesia were nonexistent. The most impor-
tant outcome of the grant awards may not be
the knowledge created and disseminated, but
rather the new cadre of investigators and schol-
ars that the grants have helped to develop by
providing a funding source and an intellectual
home for individuals who devote their careers
to patient safety.
8 Scientific Foundations

Simulation APSF helped launch the “Wake Up Safe” initia-

In the late 1980s, supported by APSF grant tive, which is a network of pediatric hospitals
funding, realistic patient simulators were in- with the goal of creating an incident-╉reporting
troduced into anesthesiology.17 Anesthesiology system and event-╉analysis paradigm. In 2007,
became the leader in the application and adop- the APSF partnered with the International
tion of simulators that provide realistic patient Anesthesia Research Society to create a patient
safety experience through education (resident safety section in the journal Anesthesia and
learning new skills for the first time on a man- Analgesia.
nequin), training (teamwork, critical event APSF-╉sponsored consensus conferences re-
management), and research (human perfor- flect efforts to maintain momentum for safety
mance). Use of realistic simulators has now initiatives, with the ultimate goal of anesthesia
become common in other medical specialties. professional associations creating best practice
policies based on these consensus conferences.
Systems-╉Based Response to Error Recently, the APSF has produced and placed
In 1987, David M. Gaba, MD, introduced the on the APSF website (www.apsf.org) videos on
concept of “normal accident theory” to the anesthesia patient safety issues (fire safety in
anesthesia literature.18 Drs. Gaba and Cooper, the operating room, medication safety, contin-
along with others, advanced the principles uous electronic monitoring of patients receiv-
of a systems-╉ based (rather that individual-╉ ing postoperative opioids, perioperative visual
based) response to error. A 1991 conference loss, simulated informed consent scenarios for
on “human error in anesthesia,” sponsored patients at risk for perioperative visual loss)
by the APSF and the US Food and Drug that can also be requested as complimentary
Administration, resulted in a better under- copies.
standing of the role of human error in an-
esthesia and in the organizational theory of E V I D E N C E D -╉B A S E D M E D I C I N E
safety in healthcare, in particular the idea of M E E T S PAT I E N T S A F E T Y
learning from high-╉risk environments such as As in aviation, many of the accepted and
aviation and nuclear power (high reliability proposed safety changes in anesthesia lack
organizations).3 evidence-╉
based support, but the common
theme is that they make sense and are the right
Advantageous Alliances thing to do (monitoring standards, audible in-
In early 2000, the APSF created the Data formation, automated information systems).
Dictionary Task Force (DDTF; http://╉w ww. Evidence from randomized trials is impor-
apsf.org/╉initiatives.php?id=1), with members tant, but it is neither sufficient nor necessary
from clinical medicine and industry, to develop for the acceptance of safety practices.21 There
a common terminology in clinical anesthesia will never be complete evidence for everything
practice that would allow computerized records that needs to be done in medicine. The prudent
and information systems to generate compat- alternative is to make reasonable judgments
ible and comparable data with standard defini- based on the best available evidence. The per-
tions.20 By 2003, the membership of the DDTF ceived decrease in anesthesia morbidity and
included representatives from the anesthesia mortality over the past 3 decades is not at-
and informatics communities in the United tributable to any single practice or the devel-
Kingdom, the Netherlands, and Canada. In opment of new anesthetic drugs, but rather to
order to reflect its international membership, the the application of a broad array of changes in
DDTF adopted as its the name the International process, equipment, organization, supervision,
Organization for Terminologies in Anesthesia training, and teamwork. These safety advances
(IOTA). have been achieved through the application
An alliance with the Society for Pediatric of a host of changes that made sense; all were
Anesthesia that included funding from the based on sound principles, technical theory,
Another random document with
no related content on Scribd:
on the intrenchments and blockhouses on the hills to the left.
The regiment was deployed on both sides of the road, and moved
forward until we came to the rearmost lines of the regulars.
We continued to move forward until I ordered a charge, and the
men rushed the blockhouse and rifle pits on the hill to the
right of our advance. They did the work in fine shape, though
suffering severely. The guidons of Troops E and G were first
planted on the summit, though the first men up were some A and
B troopers who were with me.

"We then opened fire on the intrenchments on a hill to our

left which some of the other regiments were assailing and
which they carried a few minutes later. Meanwhile we were
under a heavy rifle fire from the intrenchments along the
hills to our front, from whence they also shelled us with a
piece of field artillery until some of our marksmen silenced
it. When the men got their wind we charged again and carried
the second line of intrenchments with a rush. Swinging to the
left, we then drove the Spaniards over the brow of the chain
of hills fronting Santiago. By this time the regiments were
much mixed, and we were under a very heavy fire, both of
shrapnel and from rifles from the batteries, intrenchments,
and forts immediately in front of the city. On the extreme
front I now found myself in command with fragments of the six
cavalry regiments of the two brigades under me. The Spaniards
made one or two efforts to retake the line, but were promptly
driven back.

"Both General Sumner and you sent me word to hold the line at
all hazards, and that night we dug a line of intrenchments
across our front, using the captured Spaniards' intrenching
tools. We had nothing to eat except what we captured from the
Spaniards; but their dinners had fortunately been cooked, and
we ate them with relish, having been fighting all day. We had
no blankets and coats, and lay by the trenches all night. The
Spaniards attacked us once in the night, and at dawn they
opened a heavy artillery and rifle fire. Very great assistance
was rendered us by Lieutenant Parker's Gatling battery at
critical moments; he fought his guns at the extreme front of
the firing line in a way that repeatedly called forth the
cheers of my men. One of the Spanish batteries which was used
against us was directly in front of the hospital so that the
red cross flag flew over the battery, saving it from our fire
for a considerable period. The Spanish Mauser bullets made
clean wounds; but they also used a copper-jacketed or
brass-jacketed bullet which exploded, making very bad wounds
indeed.

"Since then we have continued to hold the ground; the food has
been short; and until today [July 4] we could not get our
blankets, coats, or shelter tents, while the men lay all day
under the fire from the Spanish batteries, intrenchments, and
guerrillas in trees, and worked all night in the trenches,
never even taking off their shoes. But they are in excellent
spirits, and ready and anxious to carry out any orders they
receive. At the end of the first day the eight troops were
commanded, two by captains, three by first lieutenants, two by
second lieutenants, and one by the sergeant whom you made
acting lieutenant. We went into the fight about 490 strong; 86
were killed or wounded, and there are about half a dozen
missing. The great heat prostrated nearly 40 men, some of them
among the best in the regiment."

Annual Reports of the War Department, 1898,

volume 1, part 2, page 684.

There have been much contradiction and controversy concerning

some of the orders by which the battle of San Juan was
directed. The following are the conclusions on that subject of
a civilian observer who seems to have seen and investigated
with impartiality:

"The orders under which the battle of San Juan was fought were
given by Adjutant-General McClernand to General Kent, commanding
the Infantry Division—consisting, in addition to the
organizations already mentioned (Wikoff's and Pearson's
brigades), of the First Brigade, including the Sixth and
Sixteenth United States Infantry and the Seventy-first New
York, under General Hawkins—at about nine o'clock in the
morning. There is no question fortunately as to the exact
wording of the orders. A little green knoll to the left of the
Santiago road and half a mile short of the San Juan Heights was
pointed out as the point which was to be the extreme limit of
the forward movement of the Infantry Division. Once there,
further orders would be given. The orders under which General
Sumner advanced from El Pozo would appear to have been more
specific, and certainly more clear than the orders which
General Kent received for the Infantry Division a few minutes
later. At the same time, it is true that these orders were
also based upon a complete misconception of the situation and
a total ignorance of the Spanish position and the lay of the
country beyond El Pozo. General Sumner's orders were to
advance along that branch of the Aguadores Creek which runs
parallel with the Santiago road from El Pozo, until it joins
the main stream of the Aguadores at the angle subsequently
known as the 'bloody angle,' where the creek makes a sharp
turn to the left, and then runs a general southerly course
toward the town of Aguadores and the sea. This creek General
Sumner was instructed to hold until the result of Lawton's
attack upon Caney became known, and he received further
orders. Once the creek was reached, Sumner, under the most
unfavorable circumstances of a heavy fire, and the thick and
pathless jungles which his men had to penetrate, deployed his
whole division, and then sent back word to McClernand, the
adjutant-general of the corps, acquainting him with the actual
conditions by which he was confronted, and asking whether his
orders contemplated an attack upon the enemy's intrenched
position, setting forth at the same time the utter
impossibility of keeping his men inactive for a long time
under such a heavy fire as was being poured in upon them.
{607}

"Had it been proposed to carry out the plan, as discussed and

agreed upon at General Shafter's headquarters the night
before, to advance along the right flank of the Spanish
position, keeping in touch with Lawton, obviously these two
divisions, or a large part of them, should have been directed
to take the direct road which ran north from El Pozo to
Marianaje and thence to El Caney, leaving in front of San Juan
only force sufficient to retain the Spaniards in their
position. But the divisions were ordered to proceed along the
Santiago road, and in a very few minutes came under fire. The
original plan may have been changed at the last moment, of
course; but as every movement that was subsequently made was
in the line of carrying this plan out, until finally, on the
12th, General Lawton succeeded in completely investing the
town on the north and west, this does not seem likely. The
more probable explanation of the movement and of what
followed, and the one accepted by general officers, is as
follows: That it was still intended to follow Lawton's advance
on the right, but that owing to our failure to develop the
Spanish position in our front, and our complete ignorance of
the lay of the land, the flank movement was not begun until
too late—not until the troops had been led into a position
from which they could be extricated only by wresting from the
Spaniards the block-houses and the trenches from which,
unexposed and unseen, they were delivering such a galling fire
upon our men, engaged in wandering aimlessly about in an
almost trackless tropical jungle. At this moment of great
confusion and uncertainty, when the road was choked with the
regiments of both the cavalry and infantry divisions, mutually
hindering one another in their struggles to advance, and
having to sustain a heavy and destructive fire which could not
be answered, an ordeal even for the veteran soldier; at this
moment, when something might still have been done to mislead
the enemy and cover our advance, the war balloon was sent up
directly behind our columns. This mistake betrayed the exact
location of our advance, and the Spanish fire became heavier
and better directed, and our losses more severe."

S. Bonsal,
The Fight for Santiago,
chapter 6 (New York: Doubleday, Page & Company).

The same writer gives a sickening account of the sufferings of

the wounded after the battle and the miserable failure of
provision for any kind of succor or care of them. "Of course:"
he says, "in view of the perilous situation which the two
divisions now occupied upon the crest of the hill, and the
great anxiety which was felt at headquarters for the safety of
the whole army, and the preparations which had to be made
against the expected night attack of the Spaniards to drive
our men back and retake their lost position, the search for
the dead and wounded this evening had to be confined to a very
limited area, and was only as thorough as the shortness of the
time for which men could be spared from the colors permitted.
The jungle and the great fields of long grass were not
searched, and thus many of the wounded were not discovered
until the following day; and quite a number, indeed, not until
the armistice was declared, on the third day after the battle,
when the men had time to ransack the hill-side and the valley
for the missing. And there were some—those who had the
strength when they fell to crawl through the cactus, the
Spanish bayonet, and all manner of prickly and trailing plants
into the deeper and more protected recesses of the jungle—who
were never discovered at all until days, many days, had
passed; and the gathering of the vultures told where some poor
fellow had died without care and without food, of his wounds
or from starvation. Of such an one, when his place of hiding
was discovered, there was, as a rule, only left a whitened
skeleton and pieces of the uniform he had worn. The last
resting place of not a few was never discovered at all.

"I believe I am giving a moderate estimate when I say that at

least one-third of the men wounded on July 1st received no
attention, and were not brought back to the division hospital
until the afternoon of Ju]y 3d. This night we knew nothing,
and had not even the slightest suspicion, of how numerous the
undiscovered wounded were. … Only about half of the wounded
men who were discovered this evening and been brought back to
the dressing station when the moon rose above the dark forest
line, and lit up the battlefield and the heights of San Juan
as clearly, and, indeed, more clearly than day, for there was
now not the dazzling force and the confusing mirage of the
pitiless sunlight to blind the sight. The majority of these
men had had their wounds dressed where they fell, or soon
after falling, with the first-aid bandages. There were very
few indeed to whom it had been possible to give any further
attention than this, as the regimental surgeons, for want of
transportation, had been unable to bring their medical chests,
and those who were best provided carried with them only small
pocket cases. …

"When the first-aid bandages were applied, the wounded man and
those who helped him were, as a rule, under fire, which made
any but the most summary methods of wound-dressing quite
impossible. Fortunately these bandages, so simple and
practical, lent themselves excellently well to this procedure.
The first thing the soldiers or the hospital attendants would
do when they came upon a wounded man was, in the case of a
wound in the body, to tear off his shirt, or in the case of a
wound in the leg, tear off his trousers, and then wrap around
the wound the first-aid bandage. The wound-dressers were
generally in such haste, and the wounded men usually so
helpless to assist in any way, and their shirts and trousers
so rotten from the drenching rains in which they had been worn
without change day or night, that the taking off of the clothing
was literally what I call it—tearing, and the garment came off
so rent as to be quite useless for further wear. Consequently
the soldiers were carried half-naked, or, if they had been
wounded in both the body and the lower limbs, as was so
 frequently the case, entirely naked, to the army wagons and so
down to the hospital, where there was not a scrap of clothing
or bedding forthcoming to cover them with. These who were
stripped in this way during the daytime were baked and
blistered by the fierce sunlight, only to shiver with the
penetrating cold and dampness after the rain had ceased to
fall and when the chill night came on.

"Knowing that he was totally unprepared to clothe or cover the

wounded that would probably be brought in, the chief surgeon
of the corps issued an order, the evening before the battle,
that all wounded men should be brought in with their blankets,
halves of shelter-tents, and ponchos when possible. This was
certainly a step in the right direction, even if it was but a
frank confession by the authorities that no preparation had
been made by them for the emergency which it cannot be said
was suddenly thrust upon them, but which they might have
foreseen and should have been preparing against for many weeks
previous.
{608}
While the attending soldiers, realizing how serious for their
wounded comrades it would be to have to lie in the hospitals
uncovered to wind and weather, made great efforts to find
their packs, these efforts were not often successful, and a
great majority of the wounded reached the hospital half
naked, and had thereafter only the covering and the bedding
which their comrades and the hospital attendants were able to
'rustle' for them, and this was little enough and not seldom
nothing at all.

"Had this expedition been provided with a greater number of

surgeons and hospital attendants, had the ambulances been at
hand which we left in Tampa or upon the transports, ambulances
without which it is reasonable to suppose—at least we had
supposed—no civilized power would enter upon an aggressive
war, much less upon a campaign in which we had the advantage
of choosing both our own time and the field of operations, the
outrageous treatment which our wounded suffered, and the
barbarous scenes which we were called upon to witness upon
this and the following days would never have occurred."

S. Bonsai,
The Fight for Santiago,
chapter 8 (New York: Doubleday, Page & Company).

The troops which had carried San Juan Hill were intrenched,
that night, in the positions they had gained, and those which
had taken El Caney were brought into connection with them,
Lawton's division on their right and Bates's brigade on the
left. The battle was renewed by the Spaniards soon after
daylight on the morning of the 2d, and raged with more or less
fury throughout the day. That evening, about 10 o'clock, a
fierce attempt was made to break through the American lines,
but without success. Again, on the morning of the third, the
Spaniards reopened battle, but with less vigor than before.
General Shafter then sent the following letter to General
Toral, the Spanish commander: "I shall be obliged, unless you
surrender, to shell Santiago de Cuba. Please inform the
citizens of foreign countries, and all women and children,
that they should leave the city before 10 o'clock to-morrow
morning." In reply, General Toral wrote; "It is my duty to say
to you that this city will not surrender, and that I will
inform the foreign consuls and inhabitants of the contents of
your message." Several of the foreign consuls at Santiago then
came into the American lines and persuaded General Shafter to
delay the shelling of the town until noon of the 5th, provided
that the Spanish forces made no demonstration meantime against
his own. This established a truce which was renewed, in a
series of negotiations until the 10th. "I was of the opinion,"
reported General Shafter, "that the Spaniards would surrender
if given a little time, and I thought this result would be
hastened if the men of their army could be made to understand
they would be well treated as prisoners of war. Acting upon
this presumption I determined to offer to return all the
wounded Spanish officers at El Caney who were able to bear
transportation, and who were willing to give their paroles not
to serve against the forces of the United States until
regularly exchanged. This offer was made and accepted. These
officers, as well as several of the wounded Spanish privates,
27 in all, were sent to their lines under the escort of some
of our mounted cavalry. Our troops were received with honors,
and I have every reason to believe the return of the Spanish
prisoners produced a good impression on their comrades. The
cessation of firing about noon on the 3d practically
terminated the battle of Santiago." General Shafter goes on to
say that when the battle was fiercest, on July 1st, he probably
had no more than 12,000 men on the firing line, not counting a
few Cubans who assisted in the attack on El Caney, and who
fought with valor. They were confronted by about equal numbers
of the enemy, in strong and intrenched positions. "Our losses
in these battles were 22 officers and 208 men killed, and 81
officers and 1,203 men wounded; missing 79. The missing, with
few exceptions, reported later." Up to this time, General
Shafter had been unable to complete the investment of the town
with his own men, and had depended upon General Garcia with
his Cubans, placed on the extreme right of the American lines,
to watch for and intercept reinforcements. They failed to do
so, and 2,800 Spaniards, under General Escario, entered the
city on the night of the 2d. The American commander now
extended his own lines as rapidly as possible and completed
the investment of the town.

Annual Reports of the War Department, 1898,

volume 1, part 2, pages 155-157.

As stated above, permission was given on the 3d for

non-combatants to leave the city. "They did leave in the
following days to the number of perhaps 20,000, filling the
neighboring villages and roads with destitute people, mostly
women and children. It then seemed to fall to our lot to see
that these people did not starve in a desolate country, and to
 be as much our duty to take care of these people, whom our
policy had driven from their homes, as it was for Spain to
feed the reconcentrados, whom they drove from their homes
under their war policy. The task was not insignificant."

Report of Inspector-General
(Annual Reports of the War Department, 1898,
volume 1, part 2, page 596).

UNITED STATES OF AMERICA: A. D. 1898 (July).

Annexation of the Hawaiian Islands.

See (in this volume)

HAWAIIAN ISLANDS: A. D. 1898.

UNITED STATES OF AMERICA: A. D. 1898 (July 1).

National Bankrupt Law.

After years of effort on the part of its advocates, a national

bankrupt law was enacted by both Houses of Congress and
received the President's signature on the 1st of July, 1898.

UNITED STATES OF AMERICA: A. D. 1898 (July 3).

Destruction of the Spanish squadron at Santiago.

On the morning of July 3, Admiral Cervera, convinced that

Santiago would be taken by the American forces, and acting
under orders from the Captain-General at Havana, made a
desperate attempt to save his squadron by escaping to sea. The
result was a total destruction of the Spanish ships, in an
engagement with the blockading fleet, of which Admiral Sampson
gave the following account in his official report:

"The enemy's vessels came out of the harbor between 9.35 and
10 a. m., the head of the column appearing around Cay Smith at
9.31 and emerging from the channel five or six minutes later.
The positions of the vessels of my command off Santiago at
 that moment were as follows: The flagship 'New York' was 4
miles east of her blockading station and about 7 miles from
the harbor entrance. She had started for Siboney, where I
intended to land, accompanied by several of my staff, and go
to the front to consult with General Shafter.
{609}
A discussion of the situation and a more definite
understanding between us of the operations proposed had been
rendered necessary by the unexpectedly strong resistance of
the Spanish garrison of Santiago. I had sent my chief of staff
on shore the day before to arrange an interview with General
Shafter, who had been suffering from heat prostration. I made
arrangements to go to his headquarters, and my flagship was in
the position mentioned above when the Spanish squadron
appeared in the channel. The remaining vessels were in or near
their usual blockading positions, distributed in a semicircle
about the harbor entrance, counting from the eastward to the
westward, in the following order: The 'Indiana' about a mile
and a half from shore, the 'Oregon'—the 'New York's' place
being between these two—the 'Iowa,' 'Texas,' and 'Brooklyn,'
the latter two miles from the shore west of Santiago. The
distance of the vessels from the harbor entrance was from 2½
to 4 miles, the latter being the limit of day blockading
distance. The length of the arc formed by the ships was about
8 miles. The 'Massachusetts' had left at 4 a. m., for
Guantanamo for coal. Her station was between the 'Iowa' and
'Texas.' The auxiliaries 'Gloucester' and 'Vixen' lay close to
the land and nearer the harbor entrance than the large
vessels, the 'Gloucester' to the eastward and the 'Vixen' to
the westward. The torpedo boat 'Ericsson' was in company with
the flagship and remained with her during the chase until
ordered to discontinue, when she rendered very efficient
service in rescuing prisoners from the burning' Vizcaya.' …

"The Spanish vessels came rapidly out of the harbor, at a

speed estimated at from 8 to 10 knots, and in the following
order: 'Infanta Maria Teresa' (flagship), 'Vizcaya,'
'Cristobal Colon,' and the 'Almirante Oquendo.' The distance
between these ships was about 800 yards, which means that from
the time the first one became visible in the upper reach of
the channel until the last one was out of the harbor an
interval of only about 12 minutes elapsed. Following the
'Oquendo,' at a distance of about 1,200 yards, came the
torpedo-boat destroyer 'Pluton,' and after her the 'Furor.'
The armored cruisers, as rapidly as they could bring their
guns to bear, opened a vigorous fire upon the blockading
vessels, and emerged from the channel shrouded in the smoke
from their guns. The men of our ships in front of the port
were at Sunday 'quarters for inspection.' The signal was made
simultaneously from several vessels, 'Enemy ships escaping,'
and general quarters was sounded. The men cheered as they
sprang to their guns, and fire was opened probably within 8
minutes by the vessels whose guns commanded the entrance. The
'New York' turned about and steamed for the escaping fleet,
flying the signal, 'Close in towards harbor entrance and
attack vessels,' and gradually increasing speed, until toward
the end of the chase she was making 16½ knots, and was rapidly
closing on the 'Cristobal Colon.' She was not, at any time,
within the range of the heavy Spanish ships, and her only part
in the firing was to receive the undivided fire from the forts
in passing the harbor entrance, and to fire a few shots at one
of the destroyers, thought at the moment to be attempting to
escape from the 'Gloucester.'

"The Spanish vessels, upon clearing the harbor, turned to the

westward in column, increasing their speed to the full power
of their engines. The heavy blockading vessels, which had
closed in towards the Morro at the instant of the enemy's
appearance, and at their best speed, delivered a rapid fire,
well sustained and destructive, which speedily overwhelmed and
silenced the Spanish fire. The initial speed of the Spaniards
carried them rapidly past the blockading vessels, and the
battle developed into a chase in which the 'Brooklyn' and
'Texas' had, at the start, the advantage of position. The
'Brooklyn' maintained this lead. The 'Oregon,' steaming with
amazing speed from the commencement of the action, took first
place. The 'Iowa' and the 'Indiana' having done good work, and
not having the speed of the other ships, were directed by me,
in succession, at about the time the 'Vizcaya' was beached, to
drop out of the chase and resume blockading stations. These
vessels rescued many prisoners. The 'Vixen,' finding that the
rush of the Spanish ships would put her between two fires, ran
outside of our own column and remained there during the battle
and chase.

"The skillful handling and gallant fighting of the

'Gloucester' excited the admiration of everyone who witnessed
it, and merits the commendation of the Navy Department. She is
a fast and entirely unprotected auxiliary vessel—the yacht
'Corsair'—and has a good battery of light rapid-fire guns. She
was lying about 2 miles from the harbor entrance, to the
southward and eastward, and immediately steamed in, opening
fire upon the large ships. Anticipating the appearance of the
'Pluton' and 'Furor,' the 'Gloucester' was slowed, thereby
gaining more rapidly a high pressure of steam, and when the
destroyers came out she steamed for them at full speed, and
was able to close to short range, while her fire was accurate,
deadly, and of great volume. During this fight the
'Gloucester' was under the fire of the Socapa Battery. Within
twenty minutes from the time they emerged from Santiago Harbor
the careers of the 'Furor' and the 'Pluton' were ended, and
two-thirds of their people killed. The 'Furor' was beached and
sunk in the surf; the 'Pluton' sank in deep water a few
minutes later. The destroyers probably suffered much injury
from the fire of the secondary batteries of the battle ships
'Iowa,' 'Indiana,' and the 'Texas,' yet I think a very
considerable factor in their speedy destruction was the fire,
at close range, of the 'Gloucester's' battery. After rescuing
the survivors of the destroyers, the 'Gloucester' did
excellent service in landing and securing the crew of the
'Infanta Maria Teresa.'
 "The method of escape attempted by the Spaniards, all steering
in the same direction, and in formation, removed all tactical
doubts or difficulties, and made plain the duty of every
United States vessel to close in, immediately engage, and
pursue. This was promptly and effectively done. As already
stated, the first rush of the Spanish squadron carried it past
a number of the blockading ships which could not immediately
work up to their best speed; but they suffered heavily in
passing, and the 'Infanta Maria Teresa' and the 'Oquendo' were
probably set on fire by shells fired during the first fifteen
minutes of the engagement. It was afterwards learned that the
'Infanta Maria Teresa's' fire main had been cut by one of our
first shots, and that she was unable to extinguish fire. With
large volumes of smoke rising from their lower decks aft,
these vessels gave up both fight and flight and ran in on the
beach—the 'Infanta Maria Teresa' at about 10.15 a. m. at Nima
Nima, 6½ miles from Santiago Harbor entrance, and the
'Almirante Oquendo' at about 10.30 a. m. at Juan Gonzales, 7
miles from the port.

{610}

"The 'Vizcaya' was still under the fire of the leading

vessels; the 'Cristobal Colon' had drawn ahead, leading the
chase, and soon passed beyond the range of the guns of the
leading American ships. The 'Vizcaya' was soon set on fire,
and, at 11.15, she turned inshore, and was beached at
Aserraderos, 15 miles from Santiago, burning fiercely, and
with her reserves of ammunition on deck already beginning to
explode. When about 10 miles west of Santiago the 'Indiana'
had been signaled to go back to the harbor entrance, and at
Aserraderos the 'Iowa' was signaled to 'Resume blockading
station.' The 'Iowa' assisted by the 'Ericsson' and the
'Hist,' took off the crew of the 'Vizcaya,' while the
'Harvard' and the 'Gloucester' rescued those of the 'Infanta
Maria Teresa' and the 'Almirante Oquendo.' This rescue of
prisoners, including the wounded, from the burning Spanish
vessels, was the occasion of some of the most daring and
gallant conduct of the day. The ships were burning fore and
aft, their guns and reserve ammunition were exploding, and it
was not known at what moment the fire would reach the main
magazines. In addition to this a heavy surf was running just
inside of the Spanish ships. But no risk deterred our officers
and men until their work of humanity was complete.

"There remained now of the Spanish ships only the 'Cristobal

Colon'—but she was their best and fastest vessel. Forced by
the situation to hug the Cuban coast, her only chance of
escape was by superior and sustained speed. When the 'Vizcaya'
went ashore, the 'Colon' was about 6 miles ahead of the
'Brooklyn' and the 'Oregon'; but her spurt was finished, and
the American ships were now gaining upon her. Behind the
'Brooklyn' and the 'Oregon' came the 'Texas,' 'Vixen,' and
'New York.' It was evident from the bridge of the 'New York'
that all the American ships were gradually overhauling the
chase, and that she had no chance of escape. At 12.50 the
'Brooklyn' and the 'Oregon' opened fire and got her range—the
'Oregon's' heavy shell striking beyond her—and at 1.20 she
gave up without firing another shot, hauled down her colors,
and ran ashore at Rio Torquino, 48 miles from Santiago.
Captain Cook, of the 'Brooklyn,' went on board to receive the
surrender. While his boat was alongside I came up in the 'New
York,' received his report, and placed the 'Oregon' in charge
of the wreck to save her, if possible, and directed the
prisoners to be transferred to the 'Resolute,' which had
followed the chase. Commodore Schley, whose chief of staff had
gone on board to receive the surrender, had directed that all
their personal effects should be retained by the officers.
This order I did not modify. The 'Cristobal Colon' was not
injured by our firing, and probably is not much injured by
beaching, though she ran ashore at high speed. The beach was
so steep that she came off by the working of the sea. But her
sea valves were opened and broken, treacherously, I am sure,
after her surrender, and despite all efforts she sank. When it
became evident that she could not be kept afloat, she was
pushed by the 'New York' bodily up on the beach, the 'New
York's' stem being placed against her for this purpose—the
ship being handled by Captain Chadwick with admirable
judgment—and sank in shoal water and may be saved. Had this
not been done she would have gone down in deep water and would
have been, to a certainty, a total loss.

"I regard this complete and important victory over the Spanish
forces as the successful finish of several weeks of arduous
and close blockade, so stringent and effective during the
night that the enemy was deterred from making the attempt to
escape at night, and deliberately elected to make the attempt
in daylight. The object of the blockade of Cervera's squadron
was fully accomplished, and each individual bore well his part
in it—the commodore in command on the second division, the
captains of ships, their officers, and men. The fire of the
battle ships was powerful and destructive, and the resistance
of the Spanish squadron was, in great part, broken almost
before they had got beyond the range of their own forts. …
Several of the [American] ships were struck—the 'Brooklyn'
more often than the others—but very slight material injury was
done, the greatest being aboard the 'Iowa.' Our loss was 1 man
killed and 1 wounded, both on the 'Brooklyn.' It is difficult to
explain this immunity from loss of life or injury to ships in
a combat with modern vessels of the best type, but Spanish
gunnery is poor at the best, and the superior weight and
accuracy of our fire speedily drove the men from their guns
and silenced their fire. This is borne out by the statements
of prisoners and by observation."

Annual Report of Secretary of the Navy, 1898,

volume 2, pages 506-511.

Some particulars of the destruction of the "Furor," the

"Pluton," and the "Infanta Maria Teresa," and of the rescue of
 surviving Spaniards, including Admiral Cervera, are given in a
report by Lieutenant Huse, executive officer of the "Gloucester,"
as follows: "The 'Pluton' was run on the rocks about 4 miles
west of Morro and blew up. Our crew cheered at the sight of
the explosion. The 'Furor' soon commenced to describe circles
with a starboard helm, her fire ceased, and it became apparent
that she was disabled. A white rag was waved from forward and
we stopped firing. Lieutenants Wood and Norman and Assistant
Engineer Proctor were sent to rescue the crews and to see if
the prizes could be saved. These found a horrible state of
affairs on the 'Furor.' The vessel was a perfect shambles. As
she was on fire and burning rapidly, they took off the living
and then rescued all they could find in the water and on the
beach. The 'Pluton' was among the rocks in the surf and could
not be boarded, but her crew had made their way ashore or were
adrift on life buoys and wreckage. These were all taken on board.
I have since learned that the 'New York' passed a number of
men in the water who had doubtless jumped overboard from the
destroyers to escape our fire. All these were probably
drowned. While this work was going on several explosions took
place on the 'Furor,' and presently—at about 11.30—she threw
her bows in the air, and turning to port slowly sank in deep
water. …

{611}

"While one of our boats was still ashore, seeing heavy clouds
of smoke behind the next point the ship was moved in that
direction, the men being at quarters and everything in
readiness for further action. On rounding the point two
men-of-war were found on the beach burning fiercely aft, the
majority of the crew being crowded on the forecastle and
unable apparently to reach land, only 200 yards away. Our
boats, under Lieutenant Norman and Ensign Edson, put off to
the nearer vessel, which proved to be the flagship 'Infanta
Maria Teresa,' and rescued all on board by landing them on the
beach through the surf. Lieutenant Norman formally received
the surrender of the commander in chief and all his officers
and men present, and as soon as all hands had been transferred
ashore, brought on board this ship all the higher officers,
including the admiral. Lieutenant Wood meanwhile rescued the
remaining survivors on board the 'Oquendo,' the second of the
burning vessels. The Spanish officers not feeling that the
prisoners on shore were secure from attack by Cuban partisans,
by your orders I directed Lieutenant Norman to land with a
small force, establish a camp on shore, and hoist the United
States flag over it. He took with him all the rations that
could be spared from the stores aboard."

Annual Report of Secretary of the Navy, 1898,

volume 2, page 542.

The following is a translation, from Admiral Cervera's report,

as partly published in newspapers at Madrid, giving his
description of the destruction of his flagship and his own
rescue from death: "The enemy's fire produced terrible damages
on board the 'Infanta Maria Teresa,' destroying the elements
of defence—among others, the net for protection against fire.
In this critical moment the captain of the ship, Señor Concas,
fell wounded, and it was necessary to withdraw him, I taking
command of the vessel, because it was impossible to find the
second commandant of the 'Maria Teresa.' Immediately
afterwards they reported to me that my cabin was burning in
consequence of an explosion. The fire soon became very great
and ignited other parts of the ship. I gave orders to my aid
to flood the after magazines, but it was impossible. Dense
clouds of smoke impeded walking in the passages and practicing
any kind of operations. In this situation I could only think
of beaching the ship, and did so, running aground on Punta
Cabrera. The contest was impossible on our side, and there was
nothing more to be done but to save as much as possible. I
thought to lower the flag, but that was not possible on
account of the fire, which prevented all operations. In these
anxious moments two boats came to the aid of the 'Maria
 Teresa,' into which a number of us jumped. Those that were not
dying were saved with nothing. The 'Teresa' lowered a small boat,
which sank before it could be of any service. Subsequently
they succeeded in launching a steam launch, but this also sank
after making one voyage to the beach. I succeeded in saving
myself with nothing, two sailors helping me, one named Andres
Sequeros and the officer D. Angel Cervera, all of us arriving
on board the American ship 'Gloucester' naked. At this time we
were all naked."

Annual Report of Secretary of the Navy, 1898,

volume 2, pages 558-559.

UNITED STATES OF AMERICA: A. D. 1898 July (4-17).

The surrender of Santiago and of all the Spanish forces
in eastern Cuba.

The following is a continuation of the report made by General

Shafter of his operations at Santiago de Cuba, resulting in
the surrender of the entire forces of Spain in eastern Cuba:
"The information of our naval victory was transmitted under
flag of truce to the Spanish commander in Santiago on July 4,
and the suggestion again made that he surrender to save
needless effusion of blood. On the same date I informed
Admiral Sampson that if he would force his way into the harbor
the city would surrender without any further sacrifice of
life. Commodore Watson replied that Admiral Sampson was
temporarily absent, but that in his (Watson's) opinion the
navy should not enter the harbor. In the meanwhile letters
passing between General Toral and myself caused the cessation
of hostilities to continue; each army, however, continued to
strengthen its intrenchments. I was still of the opinion the
Spaniards would surrender without much more fighting, and on
July 6 called General Toral's attention to the changed
conditions and at his request gave him time to consult his
home Government. This he did, asking that the British consul,
with the employees of the cable company, be permitted to
return from El Caney to the city. This I granted. The strength
of the enemy's position was such I did not wish to assault if
it could be avoided. An examination of the enemy's works, made
after the surrender, fully justified the wisdom of the course
adopted. The intrenchments could only have been carried with
very great loss of life, probably with not less than 3,000
killed and wounded.

"On July 8 General Toral offered to march out of the city with
arms and baggage, provided he would not be molested before
reaching Holguin, and to surrender to the American forces the
territory then occupied by him. I replied that while I would
submit his proposition to my home Government, I did not think
it would be accepted. In the meanwhile arrangements were made
with Admiral Sampson that when the army again engaged the
enemy the navy would assist by shelling the city from ships
stationed off Aguadores, dropping a shell every few minutes.
On July 10 the 1st Illinois and the 1st District of Columbia
arrived, and were placed on the line to the right of the
cavalry division. This enabled me to push Lawton further to
the right and to practically command the Cobra road. On the
afternoon of the date last mentioned the truce was broken off
at 4 p. m., and I determined to open with four batteries of
artillery, and went forward in person to the trenches to give
the necessary orders; but the enemy anticipated us by opening
fire with his artillery a few minutes after the hour stated.
His batteries were apparently silenced before night, while
ours continued playing upon his trenches until dark. During
this firing the navy fired from Aguadores, most of the shells
falling in the city. There was also some small-arms firing. On
this afternoon and the next morning we lost Captain Charles W.
Rowell, 2d Infantry, and 1 man killed, and Lieutenant Lutz, 2d
Infantry, and 10 men wounded. On the morning of July 11 the
bombardment by the Navy and my field guns was renewed and
continued until nearly noon, and on the same day I reported to
the Adjutant-General of the Army that the right of Ludlow's
brigade of Lawton's division rested on the bay. Thus our hold