Letter To The Editor: CRICO’s Patient Safety Leadership: A Missing Piece

To the editor:

Thank you for giving visibility to the story of CRICO’s story of leadership in patient safety. It is worthy of praise and emulation. Yet, I think there are critical pieces of the story that perhaps space didn’t permit telling, although I think they are among the most important. Then again, I have a bias because I was there.

In the mid-1980s, James Holzer, the then–director of loss prevention, approached the chiefs of anesthesia of the hospitals affiliated with Harvard Medical School (HMS), who met as an Executive Committee. Holzer told them that anesthesia malpractice premiums were among all specialties due to excessive losses. He implored them to take action to reduce the rising costs by addressing the causes of the claims. At the time, physician organizations and insurance companies generally approached malpractice costs by mounting a strong defense and advocating for legislation to limit payouts. CRICO sought to attack the problem by preventing the injuries that led to the payouts. The chiefs chose to take the same approach.

The HMS Executive Committee appointed a committee in the 1980s, with one representative from each of the five major teaching hospitals at the time—Beth Israel, Brigham and Women’s, Children’s, Deaconess, and Massachusetts General—plus Mount Auburn (one of several smaller affiliated hospitals). By virtue of my experience in the study of anesthesia adverse events, I was also asked to serve. The committee decided that we first needed to acquire data. Dr. John Eichhorn, the committee chair, was given access to the closed malpractice claims, which he summarized and reviewed with the committee. We decided that the single most important, generally common issue in these cases was the failure to adequately monitor the patient. This called for minimal standards of monitoring for all patients.

The committee formulated these minimal standards. The requirements were generally things that most would already be doing (e.g., routine monitoring of blood pressure, always being present in the room with the patient). Our rationale was to make the standard palatable and thus set a precedent for at least some safety requirements like this. This was before pulse oximetry had been widely adopted. We expected that some influential, old-school anesthesiologists in our departments would resist being required to adopt something they felt, rightly or wrongly, was not needed. As a result, pulse oximetry, a now-ubiquitous technology, was not included in the first standard (this was a point of contention in our committee and almost caused a rift). Thus were adopted the Standards for Minimal Monitoring at HMS (Eichhorn, Cooper, Cullen, Phillip, Maier, & Seman, 1986). The American Society of Anesthesiologists followed HMS’ lead and adopted a similar standard a few years later, including pulse oximetry and later capnometry. Dr. Eichhorn examined how outcomes had changed and concluded that the standards were responsible for a substantial reduction in untoward outcomes and insurance payouts (Eichhorn, 1989).

It’s also worth noting that, years later, the Anesthesia Chiefs (an entirely new team) approached CRICO seeking an incentive for all anesthesiologists to participate in the one-day Anesthesia Crisis Resource Management course conducted at the Center for Medical Simulation. The Chiefs had experienced the course and felt it would further improve anesthesia safety. The incentive program was a great success. Anesthesia malpractice costs continued to drop. The malpractice premium for anesthesiologists participating in simulation (and other, briefer activities) is 35% less than for those who don’t participate. CRICO adopted similar incentives for obstetricians (and, later, surgeons) who participate in a team-based crisis resource management course.

The other aspects of the CRICO patient safety story are important examples of how a forward-thinking insurance company can achieve a win-win-win-win (patient, provider, hospital, insurer). But, I believe it was the leadership of the HMS anesthesia Executive Committee that led to one of CRICO’s earliest and greatest successes, and that enabled the continued concentration on patient safety. More of this is described in an article authored by one of James Holzer’s successors, Robert Hanscom (2008). It is the willingness of such leaders to push the boundaries, to lead for sake of patient safety, that will continue our forward progress.


Jeffrey B. Cooper, PhD

Professor of Anaesthesia

Harvard Medical School

Massachusetts General Hospital

Executive Director, Emeritus

Center for Medical Simulation



Eichhorn, J. H. (1989). Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology, 70(4), 572–577. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/2929993

Eichhorn, J. H., Cooper, J. B., Cullen, D. J., Phillip, J. H., Maier, W. R., & Seman, R. G. (1986). Standards for patient monitoring during general anesthesia at Harvard Medical School. JAMA, 256, 1017–1020 [with editorial].

Hanscom, R. (2008). Medical simulation from an insurer’s perspective. Acad Emerg Med, 15(11), 984–987.