Anesthesia & Analgesia's supplement for education and dialog

Wrong site surgery is a “never event”: examination using root cause analysis

Wrong site surgery is a “never event”: examination using root cause analysis

  As implied by the name, “Never Events” should never occur. Health care registries can capture such sentinel events, facilitating root cause analysis to help determine how to prevent their recurrence.  Dr. Sally Rampersad, Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, Washington, and colleagues describe(…)

Root cause analysis after cardiac arrest due to local anesthetic overdose

Root cause analysis after cardiac arrest due to local anesthetic overdose

In the previous post, the authors described how Wake Up Safe (WUS) members use a standardized root cause analysis (RCA) method when adverse events occur in part to determine system changes that can be implemented to reduce future risk.  Dr. David Buck, Department of Anesthesiology, Cincinnati Children’s Hospital, Cincinnati, Ohio, and Drs. Renee Kreeger and(…)

Wake Up Safe: an effort to improve quality and safety of anesthesia care provided to children across the US

Wake Up Safe: an effort to improve quality and safety of anesthesia care provided to children across the US

Health care registries used to track adverse events can provide an important service for the health care practitioner. Registry data can reveal causes and trends that can be used to educate others, particularly for rare events that are otherwise difficult to track. Dr. Imelda Tjia, Department of Pediatric Anesthesiology, Texas Children’s Hospital, Houston, Texas, and(…)

Studies of MDCO-2010, a drug that could have potentially replaced TXA or aprotinin

Studies of MDCO-2010, a drug that could have potentially replaced TXA or aprotinin

  Blood administration is not without risk.  Antifibrinolytic agents are used to control bleeding and blood product administration.  In particular, aprotinin has been shown to have adverse effects.  In one study comparing aprotinin to tranexamic acid or aminocaproic acid in patients undergoing high-risk cardiac surgery, the trial was ended early because of a high death(…)

Emergency pages in an ambulatory surgery facility: frequency, indications, and major outcomes

Emergency pages in an ambulatory surgery facility: frequency, indications, and major outcomes

Patients who undergo ambulatory surgery procedures tend to be healthier and undergo less invasive procedures as evidenced the fact that length of hospital stay for ambulatory surgical patients is usually less than 24 hours.  It stands to reason, then, that emergency pages in ambulatory surgery facilities should be few in number. Dr. Toby N. Weingarten,(…)