Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.
ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.
Institute for Safe Medication Practices. December 7, 2021. 1:00-2:30 PM (eastern).
ISMP Medication Safety Alert! Acute care edition. October 21, 2021;26(21):1-3.
Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.
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.