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Institute for Safe Medication Practices. May 2023.
A 48-year-old obese man with a history of obstructive sleep apnea was placed under general anesthesia for corneal surgery. On completion of the operation, the patient was transferred to a motorized gurney to extubate him in a sitting position because the operating room (OR) table was too narrow. However, while the team was moving him from the OR table to the gurney, a nurse inadvertently pulled on the anesthetic machine hoses. The endotracheal tube became dislodged and the patient could not be ventilated.
A 27-year-old pregnant woman was diagnosed with severe pulmonary arterial hypertension at 29 weeks estimated gestational age (EGA) and admitted for elective cesarean delivery with lumbar epidural anesthesia at 36 weeks EGA. After epidural catheter placement, she suddenly became bradycardic and hypotensive, and within 3 minutes, developed pulseless electrical activity and cardiopulmonary resuscitation (CPR) began immediately. An emergent cesarean delivery was performed.
Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.
This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.