—Featured Article—

Flammable Surgical Preps Require Vigilance


The “fire triangle,” or “fire triad,” is taught throughout general fire safety education and is used as a point of emphasis for surgical fire prevention. Fire is the result of the combination of a fuel source, an oxidizing substance, and heat. In the operating room, alcohol-based preps and draping materials are the most common sources of fuel. Alcohol-based surgical prep solutions are excellent antiseptic agents but are also extremely flammable. In most operating rooms, the prepping and draping of the surgical patient is a role of the operating room nurse. Anesthesia providers use these same prep solutions for central line preparation and for regional anesthesia procedures. As surgical team members, our role should include increased vigilance whenever an alcohol-based prep solution is used in the operating room (OR). ... [more]

Medicolegal Data Implicate Oxygen as Common Factor in
OR Fires

Many concerns for patient safety prompt anesthesia professionals to increase the FiO2 level above 30% during surgery. These concerns include adequate oxygenation and prevention of anoxic end organ injuries, increased duration for rescue from an event that decreases oxygenation, and possible prevention of surgical site infections in certain procedures. Most anesthesia providers generally consider oxygen to be strictly beneficial without toxicity except in specific situations such as neonates and post-bleomycin treatment. An increasing number of reports in both the medical literature and the lay press regarding on-patient surgical fires associated with delivery of oxygen...[more]


ASA/APSF Ellison C. Pierce, Jr., MD, Patient Safety Memorial Lecture

Competence and Teamwork Are Not Enough:
The Value of Cognitive Aids

David M. Gaba, MD

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APSF Announces Availability of Recently Released Educational DVDs

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APSF Board of Directors Workshop

Competence and Teamwork Are Not Enough:
Implementing Emergency Manuals and Checklists

Saturday, October 11, 2014



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, MD, Treasurer; Sorin J. Brull, MD; 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: 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
1061 American Lane
Schaumburg, IL 60167-4973
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.