Humidity Levels in ORs
APSF Newsletter, June 2019
Dear Rapid Response: At our institution, we recently encountered an issue with our HVAC system that left the operating room humidity at approximately 70%. Our operating rooms were closed because…
Nitrogen Contamination of Operating Room Oxygen Pipeline
APSF Newsletter, June 2019
Dear Rapid Response: A little more than a year ago, I was on-call at a mid-sized Florida community hospital. The facility was building a new wing for interventional procedures that…
Editorial Commentary: The Challenges of Designing Monitoring Displays and Alerts
APSF Newsletter, June 2019
RAPID Response Article: Monitoring Gaps In this issue of the Newsletter, Dr. Sheron McLean describes a challenge to designing monitoring displays and alerts. Specifically, Dr. McLean identifies the potential for…
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…
Burette Malpositioned Shut Off Valve Could Lead to Venous Air Embolism
APSF Newsletter, October 2018
Venous air embolism (VAE) is a life-threatening emergency. Extensive causes of air embolism have been described in the literature.1 Embolisms from peripheral intravenous (IV) infusions are extremely rare, especially in…
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…
