ISMP

Drawn Curtains, Muted Alarms, and Diverted Attention: Tragedy in the PACU

By The Institute for Safe Medication Practices

Last April, a 17-year-old girl died following an uncomplicated tonsillectomy performed in an outpatient ambulatory surgery center after receiving a dose of IV fentaNYL in the postanesthesia care unit (PACU). The case made headline news again recently when a civil lawsuit filed by the teen’s parents was resolved. While it is too late to reverse the tragic outcome of this case, we call upon all hospitals and outpatient surgery centers to learn from the event and take action to prevent a similar tragedy in their facilities.

Editor’s Notebook

Personal Accountability

By Susan Carr

I’m struck by the number and variety of patient safety initiatives that individuals, organizations, and government entities have underway. We’re engaged in so many different activities in the name of safety and quality, it’s hard to tell if we’re headed collectively toward a coherent goal. Despite success stories and pockets of excellence, many still wonder if we’re better off than we were a decade ago. In patient safety, how can we be sure that we’re cultivating a forest and not just a vast collection of specimen trees?