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This case focuses on immediate-use medication compounding in the operating room and how the process creates situations in which medication errors can occur. The commentary discusses strategies for safe perioperative compounding and the role of standardized processes, such as checklists, to ensure medication safety.
A 48-year-old woman was placed under general anesthesia with a laryngeal mask. The anesthesiologist was distracted briefly to sign for opioid drugs in a register, and during this time, the end-tidal carbon dioxide alarm sounded. Attempts to manually ventilate the patient were unsuccessful. The anesthesiologist asked for suxamethonium (succinylcholine) but the drug refrigerator was broken and the medication had to be retrieved from another room.
Coffey SB. American Nurse Journal. Epub March 2, 2023.
Michel C, Talley C. J Health Life Sci Law. 2022;17(1):71
ISMP Medication Safety Alert! Acute care edition. January 12, 2023;28(1):1-4.
Goldstein J. New York Times. January 23, 2023.