Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 28, 2021 Publication No. NOT-HS-22-004.
ISMP Medication Safety Alert! Acute care edition. October 21, 2021;26(21):1-3.
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.
NHSX, NHS Digital, NHS England, et al. London, England: Crown Copyright; September 2021.
Graber ML, Schrandt S. Evanston, IL: Society to Improve Diagnosis in Medicine; September 8, 2021.