Keeping patients safe during anesthesia care is a multifaceted challenge. The skills and vigilance of the anesthesia professional are necessary, but not sufficient. The ergonomics of the care environment, systems…
Pharmacovigilance Applied to the Use of Sevoflurane and Desflurane: Nearly 30 years of Adverse Event ReportingThomas Ebert, MD, PhD; Alex Ritchay, MD; Aaron Sandock, BA; Shannon Dugan, BS
Sevoflurane and desflurane were introduced into the U.S. market in the early 1990s, with each having some concerns about their safety. Sevoflurane had a fresh gas flow restriction due to…
We live in a world of competing priorities when we care for patients. On any given day, we are cajoled, pushed, and even prodded to provide cost-effective, efficient, highly productive…
The MHC Story: Accelerating Implementation of Best Practices Through Improved Organizational Macro-ErgonomicsBommy Hong Mershon, MD; Philip E. Greilich, MD, MSc
Updates from the Perioperative Multi-Center Handoff Collaborative (MHC) Scaling and sustaining change in health care is complex and generally requires aligning the efforts of interdisciplinary groups on multiple levels. Examples…
Failure mode and effects analysis (FMEA) is an invaluable tool that has been used in industry to identify potential points of failure in a process, to evaluate their causes and…
This piece summarizes the content of the 2020 Ellison C. Pierce, Jr., MD, Memorial Patient Safety Lecture, which was presented on October 3, 2020, at the American Society of Anesthesiologists…
Clinical Vignette It is Friday evening and you are preparing to hand off a femoral-popliteal bypass case to the night team when you receive a page from your trainee that…
The APSF’s mission statement explicitly includes the goal to improve continually the safety of patients during anesthesia care by encouraging and conducting safety research and education. The APSF grant program…
The COVID-19 pandemic in NYC during spring 2020 resulted in an unprecedented number of patients requiring mechanical ventilation. With the need for intensive care unit (ICU) beds…
What Does Cefazolin Anaphylaxis Look Like? A Real Life Case Example A 50-year-old African-American woman presented to an Allergy and Immunology clinic following two suspected discrete episodes of anaphylaxis prior…
Malignant Hyperthermia vs. Drug-Induced MH-Like Syndromes Anesthesia professionals recognize malignant hyperthermia (MH) in the perioperative period as a rapidly progressing, life-threatening, hypermetabolic syndrome that’s triggered in the muscle of genetically…
Introduction An Anterior Neck Hematoma (ANH) can quickly progress to an airway obstruction that can occur at any time following a surgical intervention of the neck. Typically, most patients present…
The global crisis due to COVID-19 has permeated every aspect of our healthcare systems. Concerns about biohazard of (SARS-CoV-2), spread and contact transmission to patients, healthcare personnel…
Dear RAPID Response: I read your safety guidelines often for answers, but I could not find one that addresses the question of what types of procedures should be done when…
Positive pressure, where the pressure in the operating room is greater than the adjacent areas, is the typical approach to OR ventilation. This approach is employed to prevent…
Dear RAPID Response: A 4.3kg 6-week-old patient was in the operating room (OR) for repair of a ventricular septal defect. After a minor adjustment in table height using the pendant…
The Single-Provider-Operator-Anesthetist Model for Dental Deep Sedation/Anesthesia: A Major Safety Issue for ChildrenCharles J. Cote, MD, FAAP; Raeford Brown Jr, MD, FAAP; Anna Kaplan, MD
In 2019 the American Academy of Pediatrics (AAP) published a joint statement with the American Academy of Pediatric Dentistry (AAPD) updating the AAP sedation guideline.1,2 This revision was prompted by…
To Our APSF Readers:
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APSF Newsletter Podcast
Now Available Online @ APSF.org/podcast
The APSF now offers you the opportunity to learn about anesthesia patient safety on the go with the Anesthesia Patient Safety Podcast. The weekly APSF podcast is intended for anyone with an interest in perioperative patient safety. Tune in to learn more about recent APSF Newsletter articles with exclusive contributions from the authors and episodes focused on answering questions from our readers related to patient safety concerns, medical devices, and technology. In addition, special shows that highlight important COVID-19 information on airway management, ventilators, personal protective equipment, drug information, and elective surgery recommendations are available. The mission of the APSF includes being a leading voice for anesthesia patient safety around the world. You can find additional information in the show notes that accompany each episode at APSF.org. If you have suggestions for future episodes, please email us at [email protected]. You can also find the Anesthesia Patient Safety Podcast on Apple Podcasts or Spotify or anywhere that you listen to podcasts. Visit us at APSF.org/podcast and at @APSForg on Twitter, Facebook, and Instagram.
APSF 2021 Stoelting Conference
“Clinician Safety: To Care is Human”
Click the names or photos below for more information.
September 8-9, 2021
Royal Palms Resort & Spa
5200 E. Camelback Rd.
Phoenix, AZ 85018
For registration and conference inquiries, please contact Stacey Maxwell, APSF Administrator ([email protected]). Hotel reservation block to be opened at a later date.
A Remembrance: Charles Cowles, MD, MBA, FASA
In the last few days before this publication was to go to press, we learned the tragic news that Charles Cowles, MD, lost his life in a car accident on a family trip. Thankfully, his wife and three children, although injured, have all survived. Charles contributed so much to APSF and our specialty throughout his career including two articles in this issue of the Newsletter. With heavy hearts, we offer this remembrance.
Charles possessed many qualities that made him such an effective advocate for patient safety. He possessed a wealth of knowledge gained through innate curiosity, and the discipline to pursue learning until he had a thorough understanding of the topic of interest. He had the insight to understand how to apply his knowledge to enhance patient safety and the dedication to put his efforts towards that end. Finally, he generously shared his time and energy in the pursuit of improving patient care.
As a trained firefighter, Charles worked consistently for many years in an effort to ensure that no patient is injured by fire. He provided lectures and educational material as well as representing ASA at the National Fire Prevention Association (NFPA). He was an expert on facilities and the systems needed to keep patients and providers safe. Whenever called upon for an opinion, Charles provided valuable information in a form that was accessible to the clinician.
We will never know the impact Charles would have had on future safety efforts. There is no question that APSF will need to respond to patient safety concerns where we will immediately feel the loss of his guidance. Of course, our loss pales in comparison to that of his family. Our thoughts and prayers go out to them with the hope they will find some comfort being together and holding on to his memory.
We will miss Charles Cowles greatly, hold his contributions dear, and honor his memory by continuing our work on patient safety.
—Anesthesia Patient Safety Foundation
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What do all of these individuals have in common?
An abiding belief in safeguarding the future of anesthesiology. Established in 2019, the APSF Legacy Society honors those who make a gift to the foundation through their estates, wills, or trusts, thus ensuring that patient safety research and education will continue on behalf of the profession about which we are so deeply passionate.
APSF recognizes and thanks these inaugural members who have generously supported APSF through an estate or legacy gift.
For more information about planned giving, please contact Sara Moser, APSF Director of Development at: [email protected].
|More than 1,000,000 readers annually worldwide
The Official Journal of the Anesthesia Patient Safety Foundation
The Anesthesia Patient Safety Foundation Newsletter is the official publication of the nonprofit Anesthesia Patient Safety Foundation and is published three times per year in Wilmington, Delaware. Contributions to the Foundation are tax-deductible. ©Anesthesia Patient Safety Foundation, 2021.
The opinions expressed in this Newsletter are not necessarily those of the Anesthesia Patient Safety Foundation. The APSF neither writes nor promulgates standards, and the opinions expressed herein should not be construed to constitute practice standards or practice parameters. Validity of opinions presented, drug dosages, accuracy, and completeness of content are not guaranteed by the APSF.
APSF Executive Committee 2021:
Mark A. Warner, MD, President, Rochester, MN; Daniel J. Cole, MD, Vice President, Los Angeles, CA; Steven B. Greenberg, MD, Secretary, Chicago, IL; Douglas A. Bartlett, Treasurer, Boulder, CO; Lynn Reede, DNP, MBA, CRNA, FNAP, Director At-Large, Boston, MA.
APSF Newsletter Editorial Board 2021:
Steven B. Greenberg, MD, Editor, Chicago, IL; Jennifer M. Banayan, MD, Associate Editor, Chicago, IL; Edward A. Bittner, MD, PhD, Associate Editor, Boston, MA; JW Beard, MD, Wilmette, IL; Heather Colombano, MD, Winston-Salem, NC; Jan Ehrenwerth, MD, New Haven, CT; John H. Eichhorn, MD, San Jose, CA; Meghan Lane-Fall, MD, Philadelphia, PA; Nikolaus Gravenstein, MD, Gainesville, FL; Joshua Lea, CRNA, Boston, MA; Bommy Hong Mershon, MD, Baltimore, MD; Tricia A. Meyer, PharmD, Temple, TX; Glenn S. Murphy, MD, Chicago, IL; Steven Shafer MD, Stanford, CA; Brian Thomas, JD, Kansas City, MO; Felipe Urdaneta, MD, Gainesville, FL; Jeffrey S. Vender, MD, Winnetka, IL; Wilson Somerville, PhD, Editorial Assistant, Winston-Salem, NC. Please see the links of international editors at https://www.apsf.org/wp-content/uploads/newsletter/APSF-International-Editors.pdf
Address all general, contributor, and subscription correspondence to:
Stacey Maxwell, Administrator
Anesthesia Patient Safety Foundation
P.O. Box 6668
Rochester, MN 55903, U.S.A.
Address Newsletter editorial comments, questions, letters, and suggestions to:
Steven B. Greenberg, MD
Editor, APSF Newsletter
Jennifer M. Banayan, MD
Associate Editor, APSF Newsletter
Edward A. Bittner, MD, PhD
Associate Editor, APSF Newsletter
Josh Lea, CRNA
Felipe Urdaneta, MD
Send contributions to:
Anesthesia Patient Safety Foundation
P.O. Box 6668
Rochester, MN 55903, U.S.A.
Or please donate online at apsf.org/donate.