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Zipp R. Medical Tech Dive. October 18, 2021.
Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021. AHRQ Publication No. 21(22)-EHC035.
National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021
Murphy DR, Savoy A, Satterly T, et al. BMJ Health Care Inform. Epub 2021 Oct 8.
A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.