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Cases & Commentaries
- Web M&M
Matthias Görges, PhD, and J. Mark Ansermino, MBBCh, MSc; September 2014
A man with atrial fibrillation underwent ablation in the catheterization laboratory under general endotracheal anesthesia. The patient was extremely stable during the 7-hour procedure with vital signs hardly changing over time. Inadvertently, the noninvasive blood pressure measurement stopped recording for 1 hour but went unnoticed. After the error was discovered, the case continued without any problems and the patient was discharged home the next day as planned.
Oakeshott I. The Sunday Times. June 18, 2006.
This article reports on incidents of wrong drug and wrong route administration of epidurals in the United Kingdom's National Health Service.
Journal Article > Review
Woodall N, Frerk C, Cook TM. Anaesthesia. 2011;66(suppl 2):27-33.
This commentary summarizes a report on airway management safety in the United Kingdom and suggests tactics to generate improvements.
Journal Article > Commentary
Bowman S, Raghavan K, Walker IA. Anaesthesia. 2013;68:557-561.
This commentary examines how residual medications in intravenous lines can harm patients and emphasizes the need for these incidents to be reported.
Journal Article > Study
Analysis of adverse events associated with adult moderate procedural sedation outside the operating room.
Karamnov S, Sarkisian N, Grammer R, Gross WL, Urman RD. J Patient Saf. 2017;13:111-121.
The recent death of comedienne Joan Rivers, which followed a cardiac arrest during a routine throat procedure, has brought national attention to the potential safety hazards of office-based procedural anesthesia. This retrospective study examined adverse events associated with moderate procedural sedation performed outside of the operating room at a tertiary medical center. Adverse events were relatively rare, with only 52 safety incidents identified out of more than 140,000 cases over an 8-year period. The most common harm was oversedation leading to apnea and requiring the use of reversal agents or prolonged bag-mask ventilation. Women were found to be at particularly increased risk for adverse events including oversedation and hypotension. These findings suggest that a combination of patient and procedural characteristics may help risk stratify patients, allowing for appropriate responses such as increased monitoring and staffing for patients likely to experience sedation-related complications. A previous AHRQ WebM&M perspective described office-based anesthesia as the "Wild West" of patient safety.