Review of unusual patient care experiences is a cornerstone of medical education. Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to the Anesthesia Incident Reporting System (AIRS) and authors a discussion of the safety and human factors challenges involved. Real-life case histories often include multiple clinical decisions, only some of which can be discussed in the space available. Absence of commentary should not be construed as agreement with the clinical decisions described. Feedback regarding this article can be sent by email to Heather Sherman: h.sherman@asahq.org. Report incidents or download the AIRS mobile app at www.aqiairs.org.

“The patient was undergoing a laparoscopic pancreatectomy, possibly open. Epidural catheter was placed in case of open, resident told not to dose the catheter unless the surgeons converted to an open procedure, and in any event not to administer...

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