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Stories



Stories of actual anesthesia care are presented here with a goal to represent the essence of the event. The following stories have been submitted anonymously using a secure data link. No record exists regarding from where or whom stories have been submitted.

A meticulous effort is made to remove all protected health information (PHI), if inadvertently submitted, according to the "Safe Harbor Guidelines" of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Original submissions are not posted directly on this website, rather they are used as the basis for case presentations by Anesthesia e-Nonymous faculty.


Nov
23

Fire in the Operating Room

“Shortly thereafter, the electrocautery unit was utilized to facilitate excision of the lesion and almost immediately, a fire ignited.”   Case Context Provider NarrativeLessons...
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Nov
23

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 50’s; the patient was clearly gray in color.”  ...
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Nov
01

Loss of Situation Awareness Leading to Fatal Hemorrhage

“As the blankets and drapes that covered the patient were pulled back to start the arterial line, it was quickly evident that something was...
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Jul
09

Negative Pressure Pulmonary Edema with Use of a Laryngeal Mask Airway

“… at which time copious quantities of pink, frothy secretions poured out of the laryngeal mask airway as well as the mouth of the...
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May
01

Massive Pulmonary Embolism

“There were no other available extremities to place the pulse oximeter…The anesthesia provider…attempted to feel a carotid pulse, which was absent.”   Case Context...
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Mar
27

Unintentional Intraoperative Extubation

“When the ETT was slightly withdrawn, the patient was accidentally extubated.”   Case Context Provider Narrative Contributing Factors Lessons Learned   Case Context Patient:...
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Mar
20

Accidental Extubation in the Prone Position

“…the patient was returned to the supine position on a stretcher. The reason for the air leak was immediately apparent…”   Case Context Provider...
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Jan
30

Muscle Relaxant Administration Error

“Another member of the anesthesia team began going through the anesthesia drug drawer and administered something to the patient.”   Case Context Provider Narrative...
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Oct
23

Anticipated Difficult Airway

"The moment the anesthesia provider said, 'I can see the cords, please thread the tube', the patient vomited.”
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Jul
21

Stretcher Lock Failure

“The stretcher lock failed...creating a small divide between the stretcher and bed."
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