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- Communication Improvement(25)
- Computerized Provider Order Entry (CPOE)(4)
- Culture of Safety(5)
- Education and Training(16)
- Error Reporting and Analysis(26)
- Human Factors Engineering(26)
- Legal and Policy Approaches(6)
- Logistical Approaches(1)
- Policies and Operations(1)
- Quality Improvement Strategies(20)
- Research Directions(2)
- Specialization of Care(4)
- Technologic Approaches(3)
- Transparency and Accountability(1)
- Device-Related Complications(5)
- Diagnostic Errors(1)
- Discontinuities, Gaps, and Hand-Off Problems(10)
- Failure to rescue(1)
- Identification Errors(2)
- Medical Complications(3)
- Medication Safety(20)
- MRI safety(1)
- Nonsurgical Procedural Complications(1)
- Psychological and Social Complications(3)
- Second victims(2)
- Surgical Complications(61)
- Transfusion Complications(1)
- Transitions of Care(1)
A 5-day old male infant was admitted to the pediatric intensive care unit (PICU) and underwent surgery to correct a congenital heart defect. The patient’s postoperative course was complicated Staphylococcus aureus bacteremia and other problems, requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) and subsequent cardiac procedures.
Iyer R, Walker A, eds. Paediatr Anaesth. 2022;32(11):1176-1272.
An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics. In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.
This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest.
Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.
A 6-week-old infant underwent a craniotomy and excision of abnormal brain tissue for treatment of hemimegalencephaly and epilepsy.