Electronic medical devices are an integral part of patient care, providing vital life support and physiologic monitoring that improve safety throughout hospital care units. The alarms and alerts generated
As case volumes increase year after year, Non-Operating Room Anesthesia (NORA) continues to evolve,1 with NORA-based procedures comprising a larger share of modern anesthesia practice than ever before.2 Growth
Letter to the Editor I challenge you to ask yourself some introspective questions regarding anesthetic practice: Do you feel your autonomy threatened? With the constant problems of drug shortages and…
Editor’s note: In this Letter to the Editor, a reader details the challenges in maintaining adequate oxygenation and ventilation during upper GI endoscopy. This topic is related to the feature…
Letter to the Editor I read the Pro/Con Debate: Color-Coded Medication Labels in the February 2019 issue of the APSF Newsletter with interest. I found that the companion article “Pro:…
Dear Rapid Response: The American Society of Anesthesiologists standards for basic anesthetic monitoring require that all patients receiving an anesthetic have arterial blood pressure monitored, at a minimum frequency of…
RAPID Response Article: Monitoring Gaps In this issue of the Newsletter, Dr. Sheron McLean describes a challenge to designing monitoring displays and alerts. Specifically, Dr. McLean identifies the potential for…
A Critical Incident Reporting System (CIRS) collects events or circumstances that may result in unnecessary harm to patients. It is a highly useful tool for the improvement of patient
Double-Lumen-Endotracheal/Endobronchial Tube Diameter Size Indicators on Packaging Remain Suboptimal
Letter to the Editor Over two decades ago several publications warned anesthesia professionals that traditional formulas and estimations are inadequate to allow for an individualized and appropriate choice of Double-Lumen-Endotracheal/Endobronchial…
Dear Q&A, A recent event in our operating room has led me to inquire about the suitability and/or safety of using an anesthesia machine that has been saturated with water…
Dear Rapid Response: At our institution, we recently encountered an issue with our HVAC system that left the operating room humidity at approximately 70%. Our operating rooms were closed because…
Acute Citrate Toxicity Linked to Excess Citrate-Phosphate-Dextrose Solution in Autologous Blood TransfusionBrian Butala, DO; Marc Rodrigue, DO; Joshua Baisden, MD
Autologous blood transfusion used in cardiac surgery aims to minimize allogeneic blood transfusion, which is costly and associated with complications. Autologous blood is generally drawn into bags containing heparin
Dear Rapid Response: Lighted stylets are an important component of the ASA Difficult Airway Algorithm.1 Particularly useful in patients with blood or secretions in the airway, lightwands are also helpful…
APSF Trainee Quality Improvement (TQI) Recognition Program Update: Lauren Easterbrook, APRN, CRNA, DNAP
Lauren Easterbrook, RN, BSN, from the Mayo Clinic Nurse Anesthesia Program recently was recognized by the APSF for her work on patient safety involving the creation of a video entitled…
Introduction An opioid epidemic has spread across the United States as a result of the misuse, abuse, and diversion of prescribed opioid medications. Chronic opioid usage often begins with a…
Dear Rapid Response: A little more than a year ago, I was on-call at a mid-sized Florida community hospital. The facility was building a new wing for interventional procedures that…
To Our AANA Readers
As of July 1, 2019, American Association of Nurse Anesthetists members will no longer be receiving a printed copy of the APSF Newsletter as the AANA is no longer providing funds for distribution. However, because of our shared interest in patient safety, the APSF would like to provide the following two options for AANA members to receive the APSF Newsletter:
APSF Stoelting Conference 2019
“Perioperative Deterioration: Early Recognition, Rapid Intervention, and the End of Failure to Rescue”
September 4-5, 2019
The Camby, Autograph Collection
2401 E Camelback Rd
Phoenix, AZ 85016
This Stoelting Conference will include expert presentations, panel discussions, and small groups. The primary focus of this conference will be achieving consensus about key issues as they relate to the timely detection and appropriate intervention of the deteriorating perioperative patient through closely facilitated working groups. For more information about sponsoring the Stoelting Conference, please contact Sara Moser at: [email protected]f.org.
APSF gratefully acknowledges the following supporters
Stoelting Conference Supporters
Educational Grant Provider
2019 APSF Trainee Quality Improvement (TQI) Recognition Program
The project submission deadline:
August 16, 2019 at 11:59 pm
The APSF Committee on Education and Training announces the fourth annual APSF Trainee Quality Improvement Program. The 2019 program will again host tracks for resident physician anesthesiologists, student registered nurse anesthetists, and anesthesiologist assistant graduate students. The APSF invites all US and Canadian anesthesia professionals in training to demonstrate their program’s work in patient safety and QI initiatives. The APSF will accept up to two completed submissions from each US and Canadian training program in each specialty track.
More information and details on the submission process are listed on the APSF website. Additionally, please email any inquiries to [email protected]. The top two projects in each track will receive APSF recognition and financial rewards of $1,000 and $500, respectively. Resident Physician and Anesthesiologist Assistant Graduate Student winners will be announced at the 2019 Annual Meeting of the American Society of Anesthesiologists and Student Registered Nurse Anesthetist winners will be announced at the 2019 American Association of Nurse Anesthetists Annual Congress.
Is this publication worth one cafe latte per issue? If so, donate at APSF.org/fund
APSF is launching our first-ever crowdfunding initiative, defined as raising small amounts of money from a large number of people. If every individual receiving this newsletter donated $5 per issue, over $1,500,000 would be raised per year.
Help support the vision that “no one shall be harmed by anesthesia care.”
APSF Legacy Society Announcement
by Mark A. Warner, MD, APSF President
I am pleased to announce the establishment of the Anesthesia Patient Safety Foundation (APSF) Legacy Society. The APSF Legacy Society will honor those who make a gift to the foundation through their estates, wills, or trusts. Legacy Society members help safeguard the future of patient safety by ensuring that safety research and education, patient safety programs and campaigns, as well as a national and international exchange of information and ideas will continue on behalf of the profession for which we are so deeply passionate.
Become an APSF Legacy Society Member:
Legacy Society members are partners in the future of anesthesiology. To become an APSF Legacy Society member, simply inform APSF of your planned gift by contacting Sara Moser, director of development at [email protected]. We have a complimentary guide that explains more about planned giving that we can provide you as well as a membership form we ask you to complete. You do not need to provide documentation of the gift type or amount. There is no minimum gift amount for Legacy Society membership.
Members of the Legacy Society will be noted on our website and in each issue of the APSF Newsletter.
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. Individual and corporations may subscribe for $100. If multiple copies of the APSF Newsletter are needed, please contact: [email protected]. Contributions to the Foundation are tax-deductible. Copyright, Anesthesia Patient Safety Foundation, 2019.
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 2019:
Mark A. Warner, MD, President, Rochester, MN; Daniel J. Cole, MD, APSF Vice President, Los Angeles, CA; Matthew B. Weinger, MD, Secretary, Nashville, TN; Douglas A. Bartlett, APSF Treasurer, Boulder, CO; Maria van Pelt, CRNA, PhD, Director At-Large, Boston, MA.
APSF Newsletter Editorial Board 2019:
Steven B. Greenberg, MD, Editor-in-Chief, Chicago, IL; Edward A. Bittner, MD, PhD, Associate Editor, Boston, MA; Jennifer M. Banayan, MD, Associate Editor, Chicago, IL; Meghan Lane-Fall, MD, Assistant Editor, Philadelphia, PA; Trygve Armour, MD, Rochester, MN; JW Beard, MD, Wilmette, IL; Joan M. Christie, MD, St. Petersberg, FL; Heather Colombano, MD, Winston-Salem, NC; Jan Ehrenwerth, MD, New Haven, CT; John H. Eichhorn, MD, San Jose, CA; 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; Brian Thomas, JD, Kansas City, MO; 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
200 1st Street SW
Rochester, MN 55905
Address Newsletter editorial comments, questions, letters, and suggestions to:
Steven B. Greenberg, MD
Editor-in-Chief, APSF Newsletter
Edward A. Bittner, MD, PhD
Associate Editor, APSF Newsletter
Jennifer M. Banayan, MD
Associate Editor, APSF Newsletter
Meghan Lane-Fall, MD
Assistant Editor, APSF Newsletter
Send contributions to:
Anesthesia Patient Safety Foundation
200 1st St SW
Rochester, MN 55905, U.S.A.
Or please donate online at www.apsf.org/donate/.