Defective Central Venous Catheter Introducer Needle

APSF Newsletter, October 2018

We are writing to describe an incident we experienced involving a central line kit that has implications for patient safety. The case involved a 70-year-old morbidly obese patient scheduled for…

Volatile Anesthetic Unintentionally Not Delivered

APSF Newsletter, October 2018

My hospital had three incidents in the last four years that may be related to volatile anesthetics unintentionally not being delivered to the patient. After each of these incidents we…

Potential Burn Hazard from General Electric MRIs

APSF Newsletter, October 2018

Our department recently received a warning from General Electric regarding the potential hazard of patients suffering burns during magnetic resonance imaging (MRI) with its equipment. I am not aware that…

LTA Tip Breaks in Patient’s Airway

APSF Newsletter, October 2018

Anesthesia equipment malfunction may contribute to increased patient morbidity and mortality. We present a complication resulting from an accidental break in the Laryngotracheal Analgesia Device (International Medical Systems (IMS) Lidocaine…

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