—Featured Article—

Preventing Pediatric Transfusion-Associated Incidents of Hyperkalemic Cardiac Arrest

A Wake Up Safe Quality Improvement Initiative

ADr. William Paulsen

In the past 4 years, 7 cases of cardiac arrest or near-cardiac arrest associated with hyperkalemia during massive transfusion—of which 3 cases were associated wtih hyperkalemia and the remaining 4 cases were suspected of having hyperkalemia—have been reported to Wake Up Safe, a Quality Improvement Initiative of the Society for Pediatric Anesthesia. Wake Up Safe is a Patient Safety Organization that hosts a registry of serious adverse events among the now 25 pediatric hospitals that participate. The case profiles submitted were as follows: an infant undergoing myelomeningocele repair; an infant undergoing resection of an abdominal tumor; a premature neonate undergoing resection of sacrococcygeal teratoma; an infant undergoing sagittal synostectomy for craniosynostosis; a neonate undergoing resection of a facial mass; a child undergoing cardiac surgery with cardiopulmonary bypass support; a teenager in extremis undergoing emergency exploratory laparotomy for free air. .... [more]

Mixed Simulators: Seamlessly Integrating Physical and Virtual Simulation for Training in Procedural Skills and Safety

Simulation has become an accepted component of education and training in health care to the point that a formative simulation session is now a part of the high-stakes Maintenance of Certification in Anesthesiology (MOCA) exam. The APSF played an influential and seminal role in the development of mannequin patient simulators (physical simulation) through steering the nascent anesthesia-centric mannequin patient simulator designs at Stanford University and the University of Florida to include vital signs such as breath and heart sounds...[more]


Medication Safety in the Operating Room:
Time for a New Paradigm

18 minute video and DVD available online.

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APSF Announces Availability of Recently Released Educational DVDs

Request a complimentary copy...

Prevention and Management of Operating Room Fires

18 minute video and DVD available online.

Request a DVD or watch online...



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 subscription–$100, Cor­por­ate–$500. Contri­butions to the Foundation are tax deduct­ible. ©Copy­right, Anesthesia Patient Safety Foundation, 2014.
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:
Robert K. Stoelting, MD, President; Jeffrey B. Cooper, PhD, Executive Vice President; George A. Schapiro, Executive Vice President; Robert J. White, Vice President; Matthew B. Weinger, MD, Secretary; Casey D. Blitt, Treasurer; Robert A. Caplan, MD; David M. Gaba, MD; Steven K. Howard, MD; Lorri A. Lee, MD; Robert C. Morell, MD; A. William Paulsen, PhD; Richard C. Prielipp, MD; Steven R. Sanford, JD; Maria A. van Pelt, CRNA; Mark A. Warner, MD. Consultants to the Executive Committee: Sorin J. Brull, MD; John H. Eichhorn, MD; Bruce P. Hallbert, PhD.

Newsletter Editorial Board:

Robert C. Morell, MD, Co-Editor; Lorri A. Lee, MD, Co-Editor; Sorin J. Brull, MD; Joan Christie, MD; Jan Ehrenwerth, MD; John H. Eichhorn, MD; Steven B. Greenberg, MD; Glenn S. Murphy, MD; John O’Donnell, DrPH, CRNA; Wilson Somerville, PhD; Jeffery Vender, MD.

Address all general, contributor, and subscription correspondence to:

Administrator, Deanna Walker
Anesthesia Patient Safety Foundation
Building One, Suite Two
8007 South Meridian Street
Indianapolis, IN 46217-2922
e-mail address: walker@apsf.org
FAX: (317) 888-1482

Address Newsletter editorial comments, questions, letters, and suggestions to:

Robert C. Morell, MD
Senior Co-Editor, APSF Newsletter
c/o Addie Larimore, Editorial Assistant
Department of Anesthesiology
Wake Forest University School of Medicine
9th Floor CSB
Medical Center Boulevard
Winston-Salem, NC 27157-1009

e-mail: apsfeditor@yahoo.com
Or please donate ONLINE.