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Cases & Commentaries
- Web M&M
Christopher R. Lee, MD; October 2009
Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity.
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.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Describing a tubing misconnection error, this newsletter identifies contributing factors and recommends precautions to prevent similar incidents.
Journal Article > Study
The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database.
Lawal OD, Mohanty M, Elder H, et al. Expert Opin Drug Saf. 2018;17:347-357.
This study reviewed mandatory reporting of patient-controlled analgesia device-related events to the Food and Drug Administration postmarketing surveillance database. Less that 10% of reported events were deemed adverse events, and the vast majority of these were preventable. The authors call for development and adoption of patient-controlled analgesia devices with improved safety features and better training.