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Cases & Commentaries
- Web M&M
Stephen G. Pauker, MD; Susan P. Pauker, MD; May 2004
Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.
Journal Article > Review
Schmid F, Goepfert MS, Reuter DA. Crit Care. 2013;17:216.
Discussing safety issues associated with alarm monitoring in perioperative settings, this review reveals statistical and technical solutions to improve the reliability of alarm response.
Journal Article > Study
The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac surgery.
Schmid F, Goepfert MS, Kuhnt D, et al. Anesth Analg. 2011;112:78-83.
Anesthesia equipment alarms went off approximately once per minute during cardiac surgical procedures; however, 80% of these alarms had no clinical consequences. The difficulty of calibrating alarm systems was discussed in an AHRQ WebM&M interview with human factors engineering expert Donald Norman, PhD.
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.
ISMP Medication Safety Alert! Acute Care Edition. March 21, 2013;18:1-3.
This newsletter article discusses factors that contributed to the death of a patient in an ambulatory surgery center and recommends improved monitoring practices and alarm management in post-anesthesia care units.
Journal Article > Commentary
Criscitelli T. AORN J. 2016;103:518-521.