Fluid Warmers Interfere With ECG
APSF Newsletter, Spring 2009
Our hospital has recently purchased new IV fluid warmers and installed them in our operating rooms. Although the device is very effective at warming fluid, we have found that it…
Isoflurane Damages Apollo Water Trap
APSF Newsletter, Winter 2008
Anesthesia personnel have come to rely heavily upon end-tidal carbon dioxide concentration to confirm correct endotracheal tube placement and adequate ventilation. We report a case of sudden loss of end-tidal…
Machine Failure Caused by Keyboard Damage
APSF Newsletter, Fall 2008
I am the head of cardiothoracic anesthesia at St. John’s Mercy Medical Center in St. Louis and have had a unique failure of one of our newer anesthesia machines that…
Reader Ponders Relative Risks of Retrograde Arterial Flow
APSF Newsletter, Summer 2008
Reader Ponders Relative Risks of Retrograde Arterial Flow Several staff members are concerned that our invasive arterial monitoring kit (Hospira TRANSPAC IV), if flushed rapidly, can produce retrograde flow. An…
How Do Flow Sensors Work?
APSF Newsletter, Spring 2008
The information in this column is provided for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes…
The Role of ECRI in Medical Device Incidents
APSF Newsletter, Winter 2007
As coeditors of this column, it is very important that we explain to our readers what established methods of device reporting and improvement already exist within the United States. Although…