Issue PDF
Vaccine Safety: The Benefit-Risk Ratio
Steven L. Shafer, MDIn January 1976, a group of young healthy servicemen fell ill with an unknown respiratory illness at Fort Dix, a US Army training center in New Jersey. Several were hospitalized…
Articles
The APSF Revisits Its Top 10 Patient Safety Priorities
Steven Greenberg, MD, FCCP, FCCMIn 2018 the APSF Board of Directors (BOD) voted on its top perioperative patient safety priorities. This list was generated from a combination of a review of the most current literature…
Postpartum Peripheral Nerve Injuries – What is Anesthesia’s Role?
Emery H. McCrory, MD; Jennifer M. Banayan, MD; Paloma Toledo, MD, MPHPostpartum peripheral nerve injuries occur in approximately 0.3–2% of all deliveries. The majority of nerve injuries are attributed to intrinsic obstetric palsies secondary to compression…
APSF Statement on Pulse Oximetry and Skin Tone
Jeffrey Feldman, MD; Meghan Lane-Fall, MD, MSHPOn December 17, 2020, Sjoding et al. published a retrospective analysis of pulse oximetry (SpO2) data from two patient cohorts indicating that in some patients, occult hypoxemia was not detected…
Establishing a Difficult Airway Response Team for a Regional Hospital: A Case Study in the Adoption and Diffusion of Innovations
Sarah K. Pierce, CRNA; Gary E. Machlis, PhDDifficult airway adverse events are the fourth most common event in the American Society of Anesthesiologist Closed Claims Database, with detrimental or devastating…
Important Medication Errors and Hazards Reported to the ISMP National Medication Errors Reporting Program During 2020
Ronald S. Litman, DO, ML, Medical Director, ISMPThe Institute for Safe Medication Practices (ISMP.org) receives thousands of medication error reports through their voluntary practitioner online reporting system. By this mechanism…
Practice Considerations for the Anesthesia Professional for Methamphetamine Substance Use Disorder Patients
Jennifer Krogh, MSN, CRNA; Jennifer Lanzillotta-Rangeley, PhD, CRNA; Elizabeth Paratz, MD; Lynn Reede, DNP, CRNA; Linda Stone, DNP, CRNA; Joseph Szokol, MD; Laura Andrews, PhD; Joan Kearney, PhD, APRN, FAANSubstance Use Disorders (SUD) are a topic of increasing concern in the United States and continue to impact families and communities. Of the reported 329.9 million population…
CULTURE OF SAFETY: The Multidisciplinary Anesthesia Professional Relationship
Katherine A. Meese, PhD; D. Matthew Sherrer, MD, FASAA recent article in APSF by Jeffrey Cooper, PhD, highlighted the importance of considering the relationship between certain dyads in the operating room, specifically between…
Lessons Learned from Calls to the MHAUS Malignant Hyperthermia Hotline
F. Jay Garcia, MS4; Ronald S. Litman, DO, ML; Teeda Pinyavat, MDThe Malignant Hyperthermia Hotline (MHH) (800-MH-HYPER) is a service provided by the Malignant Hyperthermia Association of the United States (MHAUS), a non-profit patient advocacy…
One Year After PRODIGY—Do We Know More About Opioid-Induced Respiratory Depression?
Ashish K Khanna, MD, FCCP, FCCM, FASA; Richard D. Urman MD, MBA, FASA; Toby N. Weingarten MDThe results of the “PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY” (PRODIGY) clinical trial were published last year…
The Evolution and Role of Simulation in Medical Education
Cameron R. Smith, MD, PhD; Yong G. Peng, MD, PhD, FASE, FASAPreventable medical errors are believed to be one of the largest causes of death in the United States (US), resulting in approximately 400,000 deaths per year…
Management of Massive Intraoperative Hemorrhage
Taizoon Q. Dhoon, MD; Darren Raphael, MD; Govind RC Rajan, MBBS; Doug Vaughn, MD; Scott Engwall, MD, MBA; Shermeen Vakharia, MDHemorrhage is the leading cause of death in the operating room, with two thirds of hemorrhagic deaths occurring in the setting of emergent surgery…
RAPID Response to questions from readers
Inadvertent Unplugging of Rapid Infuser Causing a Large Volume of Cold Fluid to be Infused with Subsequent Cardiac Arrest
The ThermaCor® 1200 Rapid Infusion (Smisson-Cartledge Biomedical, Macon, GA) is a rapid heated fluid infuser, which utilizes dry, conduction temperature-controlled heating…
Laryngoscope Hook Poses Safety Issue
I would like to present a case of lower lip injury in a patient during intubation associated with the design of a Macintosh laryngoscope blade (BritePro Solo™, Flexicare Inc., Irvine, CA). The patient was a 75-year-old male who was scheduled for a urologic procedure. He was intubated smoothly with a 7.5 endotracheal tube (ETT) using…
Cardiopulmonary Arrest Precipitated by Supraglottic Kinking of Polyvinyl Endotracheal Tube
A 55-year-old male with a history of pre-existing bifasicular heart block was orally intubated uneventfully with a 7.5 millimeter Shiley polyvinyl endotracheal tube…
Announcements
To Our APSF Readers:
If you are not on our mailing list, please subscribe at https://www.apsf.org/subscribe and the APSF will send you an email of the current issue.
APSF Newsletter Podcast
Now Available Online @ APSF.org/podcast
Allison Bechtel, MD, APSF Podcast Director
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.
A Tribute to Ron Litman, DO, ML
Ron Litman, DO, ML
In this issue of the Newsletter, there are two articles by Ron Litman, DO, a frequent contributor to APSF. As the Newsletter was being finalized for publication, Ron passed away after a battle with leukemia. The articles in this issue provide a glimpse into the breadth of his career. As an MH consultant for many years, he took calls at all hours of the day and night, advising colleagues faced with patient care decisions to recognize and treat malignant hyperthermia. He was not only a world expert on MH, but an important voice for MHAUS (Malignant Hyperthermia Association of the US), serving as the medical director from 2013 to 2019. Of note, his article on lessons learned from the MH hotline was authored with a medical student, one of countless students and residents he mentored with the goal of inspiring them to a career of inquiry and contribution. Ron also had a longstanding interest in medication safety and served as medical director for ISMP (the Institute for Safe Medical Practices) and as former Chair of the FDA Anesthetic and Analgesic Drug Products Advisory Committee. Ron was a leading voice in pediatric anesthesia, contributing to our understanding of the pediatric airway, and inspiring many to contribute to the field. He had a thirst for knowledge and found time to earn a Masters of Law degree in recent years. He did it all with humor and a very human touch. Ron’s passing is a great loss, not only to his family and friends, but to our specialty and the patients we serve.
Jeffrey M. Feldman, MD, MSE
Attending Anesthesiologist, Children’s Hospital of Philadelphia
Professor of Clinical Anesthesiology
Perelman School of Medicine
University of Pennsylvania
APSF 2021 Stoelting Conference
“Clinician Safety: To Care is Human”
Click the names or photos below for more information.
Hosts:
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]).
For information on sponsoring the Stoelting Conference, please contact Sara Moser, APSF Director of Development ([email protected]).
Stoelting Conference Supporters
  |
Anesthesia Quality and Patient Safety Meeting
Jul 17, 2021—Featured ASA Event, Virtual
Acquire strategies and innovations that optimize patient care, decrease burnout, reduce medical errors, and improve a culture of safety.
The new Anesthesia Quality and Patient Safety Meeting 2021 focuses on key themes in quality improvement, patient safety, team collaboration, and wellness. The meeting includes renowned practitioners.
Quality and safety are a team endeavor—the more team members you bring, the greater the discount:
GET NOTIFIED WHEN REGISTRATION OPENS
This virtual meeting is made possible through collaboration between ASA and AQI with support from APSF. Interested parties can sign up for email notifications using this link.
Credit: This activity has been approved for AMA PRA Category 1 credit™.
Join the #APSFCrowd!
Donate now at APSF.ORG/FUND
The Anesthesia Patient Safety Foundation is launching our first-ever crowdfunding initiative, defined as raising small amounts of money from a large number of people.
Just $15 can go a long way to reach our goals.
Help support the vision that “no one shall be harmed by anesthesia care.”
YOUR CONTRIBUTION PROVIDES FUNDING FOR IMPORTANT PROGRAMS:
The APSF Newsletter is now translated into the following languages: Chinese, French, Japanese, Portuguese, and Spanish.
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].
Join us!
| 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, 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.
[email protected]
Address Newsletter editorial comments, questions, letters, and suggestions to:
Steven B. Greenberg, MD
Editor, APSF Newsletter
[email protected]
Jennifer M. Banayan, MD
Editor, APSF Newsletter
[email protected]
Edward A. Bittner, MD, PhD
Associate Editor, APSF Newsletter
[email protected]
Online Editors:
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.