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The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8.
This WebM&M describes an adverse event due to mislabeling or “syringe swap” in a preoperative patient. The commentary outlines several recommendations and safeguards to ensure that medications administration is safe.
Institute for Safe Medication Practices
Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765
ECRI and Institute for Safe Medication Practices. January 2022 through May 2022.
Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.
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.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 27, 2021.
Ruskin KJ, ed. Curr Opin Anaesthesiol. 2020;33(6):774-822.