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- Clinical Guideline(1)
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Although wrong-site surgeries are rare, they can be devastating to patients. One otolaryngology (ENT) clinic developed a surgical marking procedure deemed practicable and useful by both providers and patients.
Improving non-technical skills - such as teamwork and communication – is essential to safe delivery of healthcare but implementing successful training programs has been challenging.
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.
Tan JM, Cannesson MP. APSF Newsletter. 2023;38(2):1,3–4,7.
A 62-year-old Spanish-speaking woman presented to the pre-anesthesia area for elective removal of a left thigh lipoma. Expecting a relatively simple outpatient operation, the anesthesiologist opted not to use a Spanish language translator and performed a quick pre-anesthesia evaluation, obtaining her history from the medical record. Unknown to the anesthesiologist, the patient was trying to communicate to him that she had undergone jaw replacement surgery and that her mouth opening was therefore anatomically limited.