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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.
ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.
Järvinen TLN, Rickert J, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.
Kaplan A. NBC News. October 27, 2022.
Kelman B. Kaiser Health News. March 22, 2022