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Meyer TA. Anesthesiology News. October 31, 2022.
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
This WebM&M highlights two instances where incomplete documentation of patient history led to complications related to anesthesia administration. The commentary discusses the importance of a thorough preoperative history and preoperative evaluation.
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
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.