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…
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…
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…
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…
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…
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…