Anesthesia Patient Safety Podcast

#280 Speak Up To Save Lives

• Anesthesia Patient Safety Foundation • Episode 280

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What if the biggest risks in maternal care are not just clinical, but cultural? We dig into the hard truth that speaking up can feel risky, pain during cesarean is often underestimated, and rare obstetric crises can overwhelm memory. From there, we chart a path toward safer births with practical tools that any team can use: psychological safety to unlock communication, structured pre‑briefs and rapid debriefs, and cognitive aids that turn chaos into coordinated action.

We walk through the lived reality of intraoperative pain—why negative skin tests don’t guarantee visceral coverage, how fear of general anesthesia can delay needed care, and the downstream consequences for bonding, breastfeeding, and mental health. You’ll hear clear, patient‑centered steps: standard sensory assessment, explicit pain check‑ins, decisive treatment or conversion when indicated, and honest conversations that validate experience. The message is simple and urgent: pain is preventable harm, and timely action saves more than minutes—it protects families.

Readiness matters beyond big hospitals. Rural teams face OB unit closures, low volumes, and limited resources. Mobile simulation and statewide programs show how to keep skills sharp for postpartum hemorrhage, eclampsia, and high‑risk transfers. We also highlight the Four Ps for anesthesia professionals—presence, preemption, proficiency, and platform—to embed safety into daily practice, from risk screening to standardized pathways. Finally, we extend the safety net into the community with sepsis bundles and accessible education so patients and their support networks recognize warning signs and act fast. Along the way, we touch on pediatric safety and emerging evidence that EEG‑guided anesthesia can reduce emergence delirium.

If transforming maternal care speaks to you, join us. Subscribe, share this episode with a colleague, and leave a review with one change your team will make this month. Your insight could be the spark another unit needs to save a life.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/280-speak-up-to-save-lives/

© 2025, The Anesthesia Patient Safety Foundation

SPEAKER_01:

And so this has actually become a research focus for me. This idea of speaking up. Why is it so hard? Why do we self-censor ourselves in these critical moments? And why do we do this calculus that somehow makes us feel that the risk to ourself in the moment is greater than the potential risk to a patient?

SPEAKER_00:

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel, and I'm your host. Thank you for joining us for another show. We are wrapping up our exciting series today, all about the 2025 APSF Stolting Conference, Transforming Maternal Care, Innovations and Collaborations to Reduce Morbidity and Mortality. If you weren't able to attend the Stolting Conference this year, then we hope that you will enjoy this five-part podcast series and you can check out recordings from the conference on the APSF website and YouTube channel. Check out the show notes for more information. Before we dive further into the episode today, we'd like to recognize Preferred Physicians Medical, a major corporate supporter of APSF. Preferred Physicians Medical has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, Preferred Physicians Medical. We wouldn't be able to do all that we do without you. Now it's time to get back into the conference talks and return our focus to transforming maternal care. Thank you to our industry sponsors for supporting the 2025 APSF Stolting Conference, BD, Medtronic, Solventum, and IntelliGuard. Our next session is intrapartum challenges and emergencies. We are going rapid fire with lots of highlights today. The first speaker is May P. Smith, a senior obstetric anesthesiologist to talk about communication and trust. Our problems are our opportunities. May reminds us that communication errors lead to sentinel events, and in most cases, someone on the team knew something important but did not speak up. We know that despite our best intentions, errors still happen. This is why communication is so important to mitigate harm from inevitable errors. There is a cycle between communication as a marker for psychological safety and improving communication as a driver for improving safety culture. The opposite is also true. Distrust is a barrier to dissemination of best practices. Individual and systemic distrust affect access to care, management, treatment, and outcomes. So what is good quality communication? This is communication that is frequent, timely, accurate, and problem solving. This is absolutely what we want from our colleagues in an emergency. Good relationships involve shared goals and knowledge with mutual respect, and this leads to long-term trust and respect, which is a key for transforming outcomes. There are improved outcomes in areas with relational coordination and good quality communication and relationships. These outcomes include decreased hospital length of stay, mitigated harm from medical errors, mitigated harm from perioperative adverse events, and decreased rates of infection. Additional benefits for healthcare team members include improved resiliency, decreased clinician burnout, increased job satisfaction and engagement, increased self-efficacy and innovation, increased courage, and increased gratitude. Let's bring this on to the maternity ward. The combination of respectful maternity care, trusted messengers such as doulas or group prenatal care, and language access with interpreters can have a big impact on maternal patient safety. We also need shared mental models, which involves pre-briefs, checklists, closed loop communication, and rapid debriefs. May provides some very practical advice. Invite team members to speak up during the case. And when someone does speak up, and even if they are wrong, it is important to thank them for speaking up. This helps team members to continue to speak up in the future. Another important consideration is how to gain trust quickly by applying the golden rule and being respectful and treating others how we would like to be treated. We can go one step further to the platinum rule: treat others as they would like to be treated. This means that there needs to be a pause since the patient may be coming from a totally different place. We need this pause to figure out where the patient is coming from. Now let's head into the operating room to talk about inadequately treated pain. Our next speaker is Heather Nixon, a professor of anesthesiology at the University of Illinois at Chicago. Have you listened to the podcast, The Retrievals Season 2? If not, you can add it to your list, and I will include a link in the show notes. Heather gives us a call to action that pain during C-section is real and it is traumatic. Here are some of the lessons learned that she shares with us during her talk. Number one, neuraxial is not always enough. Not all of our neuraxial blocks cover visceral pain. So even when the skin test is negative, patients can still feel pain. We may need to use adjuncts during the C-section, including other medications or conversion to general anesthesia. Number two, for patients with a history of anxiety or being anxious, this does not mean that these patients are not experiencing pain. Check out the 2022 article by Kelts and colleagues, which revealed that intoperative pain occurred in about 12% of patients undergoing elective C-section delivery under spinal anesthesia. Anesthesia professionals underestimated the incidence of intoperative pain. You can find the citation in the show notes. Number three, anesthesia professionals are bad at communicating with our patients. Number four, fear drives a lot of our choices. There is this belief that if I have to induce general anesthesia, there is a chance that I will lose the airway and the patient will die. There is a fear of impacting breastfeeding and a fear of being judged. Number five, a focus on the fetus, which may prevent us from treating pain in a timely manner if we need to wait until after delivery. In addition, if we say that's okay because the baby is okay, that may alienate patients who have suffered trauma. Number six, the culture in the operating room is important. We need to make sure that there is a shared mental model between the anesthesiologist, the OB, and the nurses. And number seven, there are consequences to this untreated pain, including decreased maternal infant bonding, decreased breastfeeding, post-traumatic stress disorder, higher rates of depression, higher rates of divorce, and resistance to further pregnancy. So what can we do? Here are some important considerations for improving maternal patient safety during C-section delivery. Preoperative discussion about the risks of anesthesia and the options. Standardized sensory assessments, including skin tests around the incision. Then, when the patient reports pain, it is important to localize the pain and treat depending on where we are in the surgery. Have a conversation about pain expectations and interoperative communications. Surgical interventions, which may involve not exteriorizing the uterus or shorter surgical times. Patient-centered communication. You can let patients know that pain is important and every 15 minutes or so we will be monitoring pain scores. You are not supposed to suffer, but you need to let us know. Then, if the pain score is greater than 3, stop the surgery and evaluate the patient's pain. Education and coaching. An accountability for the entire team to speak out. And finally, debriefings. Did the patient have pain? Could we predict this? How did we respond? And how was our communication? Heather leaves us with a call to action that this is a health risk. This is preventable harm. Going forward, we need a safety bundle for pain during C-section delivery to help keep our patients safe. Our next speaker is Coquila Venuara, clinical professor of obstetric anesthesia, to talk about simulation for addressing challenges in rural settings. Coquila outlines the scope of the problem with rural hospital closures, OB unit closures, and challenges to access OB services. These challenges stem from the high cost to maintain OB units. They are expensive with 24-hour staffing, access to the operating room, and in rural areas, limited number of cases. Plus, clinicians working in these settings may have limited specialized training, no obstetricians but family practitioners with OB training, low patient volumes, so difficulty maintaining skills, and limited availability of critical resources, including blood bank and lab services. There are limited resources available in these settings. Enter Simulation Training. This is a way to improve and maintain OB skills in rural hospitals. The Iowa statewide perinatal care program provides comprehensive quality and safety support to Iowa's birthing hospitals. One of their programs is the OBED Simulation Training Program, which involves their statewide obstetric mobile simulation team to help educate ER and EMS providers with didactics and skill stations on normal deliveries, active management of third stage of labor, recognizing postpartum hemorrhage, recognizing severe pre-eclampsia, management of eclampsia, stabilizing and transfer of high-risk OB patients. There is so much more to this program, and we hope that you will check out the link in the show notes. Coquila leaves us with a call to action. What can anesthesiologists do to help develop practical and sustainable solutions to improve maternal care in rural settings? The answers to this question will be vital for improving maternal safety in rural settings going forward. The final speaker for this session is Alex Hanenberg, a senior research scientist and core faculty member of Ariande Labs to talk about addressing obstetric crises with checklists. Alex makes the argument that we need these crises checklists because these are high stress and rare events. So we cannot rely on memory for the key steps of management. Plus, there is a high potential for morbidity and mortality, and we need a rapid response. During an OB crisis, this is a situation where we need to create a shared mental model and make sure that we are all on the same page. This is one of our themes today. There is overwhelming evidence that the way to do this is with a cognitive aid to improve performance. It is like having the answer sheet to the highest stakes test. So, what can you do to make sure that you are doing the best job you can for your patient? Using checklists is an important step, as well as using real-time debriefings after events. This may require a change in practice and culture at your institution until using checklists is just part of the safety culture where every team member has a role from developing and refining the checklists, triggering the checklist use, reading through the checklist, and advocating and supporting their use. A robust implementation program can help. Check out the show notes for more details. Alex reminds us that these tools have value and can be embraced and used effectively in the presence of humility. We need to be able to accept the fact that we could miss something. And when we pull out the checklist, that is best practice. Our next speaker is going to offer action items for how anesthesia professionals can move the needle on maternal safety. Brian Bateman is a professor of anesthesiology and chair at Stanford University. We have the skills and training with critically ill patients in the operating room or ICU. And we can bring this to the labor and delivery units as well. Brian brings us through the four Ps for how anesthesia professionals can improve maternal patient safety. First, presence on the labor and delivery unit and in the operating room when a rapid response is needed, and also when we follow patients from labor to delivery and then to postpartum. Next, preemption, which involves optimizing management and screening for high-risk patients pre-delivery. This step allows us to intervene early when we can. The obstetrics comorbidity index is a tool that can help. I've included more information about calculating this in the show notes as well. The third P is for proficiency. Considerations here include using our expertise and training to help guide resuscitation and transfusion, pain management, and procedural expertise when it comes to lines, monitors, airway, regional, and neuraxial. We have a lot to offer when it comes to peripartum care. The final P is for platform, which involves using standardized care pathways and order set defaults to drive quality improvement and reduce maternal morbidity and mortality. There is another plug for the important role of multidisciplinary collaboration, simulation, debriefing, and building a safety culture to reach these goals. Anesthesia professionals can use the four Ps framework to help move the needle at their institutions as safety champions who build safety into the systems so that interventions stick and create a system that is constantly learning. One way to move the needle on a wider regional, national, or international scale is continued work on multidisciplinary guidelines to help guide safe care. We hope that you will check out the 2025 consensus statement on pain management for pregnant patients with opioid use disorder. These are multidisciplinary guidelines published just this year. You can find the citation in the show notes as well. And finally, Brian leaves us with a call to action when it comes to research. We need to partner with experts across the clinical and research spectrum to move beyond epidural dosing to examine big ideas for the most pressing problems in maternal health. We are going to switch gears now to talk about coordinating in the community and how we can help decrease serious postpartum morbidity. Our speaker is Melissa Bauer, an associate professor of anesthesiology who shares her experiences with implementation of the sepsis bundles with the goal to work through the entire time period from pregnancy, labor and delivery, and postpartum with the help of community leaders and patient involvement. Since most patients do not have risk factors and may not present with fever, how can we help patients know when to seek care and feel heard when they do seek care? The Alliance for Innovation on Maternal Health Consensus Bundle on sepsis and obstetric care has some important resources, including standardized patient education, including the severe maternal morbidity warning signs. Patient education may involve phone discharge education or even a business card with a QR code that provides the information that they need. Community dissemination of information is also important and can be done through public health campaigns, community-based organizations, houses of worship, doulas, and home visiting nursing programs. Keep in mind, when patients think that something is wrong, they don't call their doctor, they call their friends and family. So we need to get this information out there so that the friend can say, oh, you need to go to the hospital. Let's continue the conversation in the community with our next talk given by Megan Rosenstein, an anesthesiologist and associate chief medical officer at Overlook Medical Center, and her talk, From Clinic to Birth, a Team Approach. Megan introduces the scope of the problem at her institution, high hemorrhage rates, despite trying to align the team with best practices. So here's what they did: brought together a multidisciplinary team with three phases, including antipartum, intrapartum, and postpartum. In the antipartum phase, the team evaluated risk factor modification for anemia with department endorsement and involvement of stakeholders. The plan involved practice visits to identify barriers early, followed by reducing these barriers to care with priority consultation to make it easier for patients to get diagnosed and to get an iron infusion if needed, and continued work with scorecard integration for monitoring. The intrapartum phase involved hemorrhage prevention, reducing avoidable C-sections, hemorrhage prophylaxis, and considerations for surgical technique. The postpartum phase included early recognition and management, quantitative blood loss, and situational awareness with enhanced recognition and management. Megan reminds us that these are not novel strategies, but when used consistently and altogether, they can be effective, and the anesthesiologist has an important role in teaming and change management to improve maternal patient safety. Our final speaker is Yasuko Nagasaka, the chair and professor in anesthesia at Tokyo Women's Medical University, to talk about enhancing maternal and pediatric anesthesia safety in Japan. Yasuko asked some important questions about the impact of epidurals on maternal mental health. We still don't know the answer to this since there are conflicting results. What about the safety of medications given during labor and delivery on the developing brain? The gas study was the first prospective clinical trial to explore the effects of anesthetics on the developing brain. It was an international and multi-center randomized control trial that compared regional and awake to regional placebo fluorine with no significant differences between the groups at ages two and five years old. Another important question for pediatric patient safety is why do small children develop emergence agitation and delirium? There is an interesting study that evaluated EEG-guided titration of sevofluorine with reduced pediatric emergence delirium. The control group was given standard fixed level of sevofluorine administration, while the intervention group received sevofluorine administration titrated to EEG. The intervention group had lower scores for agitation and emergence delirium with 25 minutes faster emergence and 20 minutes earlier discharge. Going forward, EEG may be an important tool to help improve pediatric anesthesia safety. And that's a wrap on the 2025 APSF Stolting Conference. We hope that you enjoyed this series and are inspired to continue the work to transform and improve maternal patient safety going forward. We hope that you will share this podcast with one person, tell a friend or a coworker or a trainee or even an administrator, even one person can make a difference. We want to get the word out there so that more people are working to transform maternal care and improve anesthesia patient safety. If you have any questions or comments from today's show, please email us at podcast atapsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.