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IV Failure in the ICU

“Upon inspection of the IV site, a swollen and mottled hand was noted.” Case Context…

Anesthesia Machine Close Call

“Unexpectedly, the CO2 canister immediately dropped to the floor with a loud thud.” Case Context…

Corneal Abrasion

“…the patient complained of excruciating pain in the left eye to the point she could…

Narcotized in the PACU

“The anesthesia provider asked for an Ambu® bag and the recovery room nurse realized all…

Anesthesia Machine Failure

“Everything went black. Once the power came back on, the provider attempted ventilation and could…

Pulseless Electrical Activity

“…the surgeon requested that the head of the bed be raised another 20° for improved…

Tunnel Vision

“The manual BP was attempted several times with only a single reading obtained, which was…

Fire in the Operating Room

Electrocautery Unit Fire in the Operating Room

“Shortly thereafter, the electrocautery unit was utilized to facilitate excision of the lesion and almost…

Failed Intubation and Mask Ventilation in an Emergency Cesarean Section

”There was no chest rise, no ETCO2, and the oxygen saturation was plummeting into the…

Loss of Situation Awareness Leading to Fatal Hemorrhage

“As the blankets and drapes that covered the patient were pulled back to start the…