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Table of Contents





                     Introduction ................................................................................................... 7

                     Documentation ........................................................................................... 11


                       Pre-Anesthesia ................................................................................................ 12

                       Intraoperative .................................................................................................. 22

                       Post-Anesthesia ............................................................................................. 28

                     Communication ........................................................................................ 34


                       Electronic Communication...................................................................... 40

                       CRNA Oversight ............................................................................................. 41

                     Medication Errors ..................................................................................... 51

                       MAC Anesthesia ............................................................................................. 51


                       Infusion Line Issues ..................................................................................... 52

                     Additional Indefensibility Issues ...................................................... 53

                       Positioning ......................................................................................................... 54

                       Dental Issues ................................................................................................... 55

                       Inappropriate Response to Emergencies ...................................... 57


                       Intraoperative Burns .................................................................................... 64

                       Anesthesia Awareness .............................................................................. 66

                       Distracting Devices ...................................................................................... 68

                     Conclusion ................................................................................................... 73
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