Medication errors in anesthesia: unacceptable or unavoidable?

Acute Pulmonary Edema During a Cesarean Delivery After an Adverse Drug Event

Acute pulmonary edema (APEd) is rare in pregnancy and in the postpartum period. An intermediate type of APEd characterized as a transudate with a protein concentration between that of cardiogenic and noncardiogenic APEd has been described in the literature. This transudate might actually be the result of capillary pressure having increased to a point of high-permeability edema and/or alveolar hemorrhage. Clinically, the presentation would be a dramatic form of APEd - flash pulmonary edema - characterized by a rapid accumulation of fluid within the lung's interstitial and alveolar spaces as a result of suddenly elevated cardiac filling pressures. Here, we present a case of a healthy pregnant woman who underwent cesarean delivery and developed a constellation of signs and symptoms, suggestive of an APEd, after a supratherapeutic bolus of phenylephrine. During the diagnostic excursion, bilateral parenchymal infiltrations suggestive of hemorrhage were observed on a computed tomography scan. This case highlights the high morbidity associated with adverse drug events and the imperative to prevent them. It also underscores the critical need for careful management of volume shifts and hemodynamics in full-term pregnancies.

Intravenous therapy device labeling in Intensive Care Units: an integrative review

OBJECTIVES

to synthesize the evidence on intravenous device labeling used to identify medications administered to patients in Intensive Care Units, with a view to preventing medication errors.

METHODS

an integrative review, in the LILACS, IBECS, Embase, MEDLINE, Scopus, Web of Science and CINAHL databases, from November to December 2021, using descriptors and selection criteria. Data were collected in 11 articles and subsequently classified, summarized and aggregated.

RESULTS

pre-designed labels, with pre-defined colors and information, help to prevent medication identification errors. There is still a lack of standardization in the practice of labeling syringes, intravenous lines, infusion pumps and saline solution bags. There are errors related to the lack of labeling devices or to their performance with incomplete information.

CONCLUSIONS

device labeling is a barrier to defending the medication system safety and should be standardized.

Human errors and their prevention in healthcare

Human errors form a significant portion of preventable mishaps in healthcare. Even the most competent clinicians are not immune to it. Errors in the perioperative period can often have grave consequences, and hence, perioperative clinicians need to be aware of the impact of human errors and how to minimize them. Errors are broadly classified into two kinds: latent and active errors. While active errors need to be addressed at the individual level, latent errors indicate organizational inadequacies. This review describes common errors in perioperative settings, the impact of such errors on healthcare, and preventive strategies to minimize such errors in daily patient care.

Pharmacology Course Redesign Using High-Impact Practices

BACKGROUND

Although pharmacology serves as a foundation for health care professions, a gap exists between education and the clinical application. Experiential learning has demonstrated benefit when integrated into pharmacology courses; however, professors struggle with the challenge of incorporating active learning modalities into traditional lecture courses.

METHOD

Active learning and high-impact educational practices, based on cognitive theory, were incorporated into a pharmacology course sequence. After course completion and entry into the clinical setting, qualitative data were collected from students and clinical preceptors.

RESULTS

Students and clinical preceptors reported an improvement in students' ability to recall and apply concepts clinically. Students identified the creation of cognitive aids as the most advantageous measure.

CONCLUSION

Integrating active learning and high-impact educational practices into pharmacology courses could potentially aid in the ability to recall and apply concepts clinically, reduce medication errors and expenditures, and increase student confidence when entering clinical education. [J Nurs Educ. 2021;60(9):529-533.].

Anesthetic consideration for patients with micra leadless pacemaker

MICRA, miniaturized leadless single chamber pacemaker, is inserted directly into the right ventricular myocardium via transcatheter approach. We present a case of a 66-year-old patient with a Micra pacemaker scheduled for kidney-pancreas transplant. The patient is pacemaker dependent. The preoperative cardiology consult did not comment on the need of reprogramming. One hour prior to the surgery, the anesthesia team was unable to locate the pacemaker on the chest wall. The Medtronic hotline was called, and the caregivers learned that the particular pacemaker is buried within the ventricular wall and is not responsive to an external magnet. Thus, the case was delayed and a cardiac electrophysiology team was contacted to reprogram the pacemaker to VOO (fixed ventricular pacing) mode. We suggest that the pacemaker can pose perioperative challenges due to its novelty, paucity of report, and guidelines.