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psnet.ahrq.gov/periodic-issue/periodic-issue-399
July 31, 2023 - Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery … The most frequent never events were wrong site or wrong patient surgery, wrong surgical procedure, and … An abdominal x-ray confirmed a large amount of stool in the colon with no free air and her blood leukocyte … the surgeon found stercoral colitis and a large perforated “stercoral ulcer” of the proximal sigmoid colon
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psnet.ahrq.gov/web-mm/bloody-bp-cuff
June 21, 2016 - Patient #1 was taken to surgery where he coded and died about an hour later. … Chief, Section of Minimally Invasive Surgery Division of General Surgery, Department of Surgery, University … More About The Topic
Emergency Departments
Health Care Providers
Emergency Medicine
Surgery
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psnet.ahrq.gov/node/866261/psn-pdf
July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy
Position for Laparoscopic Gynecological Surgery
July … Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic
Gynecological Surgery. … Avoiding, diagnosing and treating well leg compartment
syndrome after pelvic surgery. … Lower limb (well leg) compartment syndrome after urological pelvic
surgery. … Dis Colon Rectum.
2019;62(10):1150-1152.
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psnet.ahrq.gov/node/49686/psn-pdf
May 01, 2013 - A computed tomography scan in the emergency department revealed acute
appendicitis and surgery was recommended … vascular access nurse disagreed and advised that the port should be used for
vascular access during surgery … Surgery was
canceled, and she was placed on anticoagulation therapy and managed conservatively for appendicitis … Kuriakose P, Colon-Otero G, Paz-Fumagalli R.
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psnet.ahrq.gov/node/49398/psn-pdf
May 01, 2003 - Patient #1 was taken to surgery where he coded and died about an hour later. … Chief, Section of Minimally Invasive
Surgery Division of General Surgery, Department of Surgery, University
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psnet.ahrq.gov/periodic-issue/periodic-issue-419
November 29, 2023 - Review
Overlapping surgery in orthopaedics: a review of efficacy, surgical costs … selected a jug of dialysis liquid rather than a polyethylene glycol solution commonly used to clean the colon
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery. … the need for gram-negative bacterial coverage in antibiotic prophylaxis for oncological head and neck surgery … The Topic
Hospitals
Health Care Providers
Health Care Executives and Administrators
Surgery
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psnet.ahrq.gov/periodic-issue/periodic-issue-400
July 31, 2023 - Root causes and preventability of unintentionally retained foreign objects after surgery … An abdominal x-ray confirmed a large amount of stool in the colon with no free air and her blood leukocyte … the surgeon found stercoral colitis and a large perforated “stercoral ulcer” of the proximal sigmoid colon
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psnet.ahrq.gov/periodic-issue/periodic-issue-405
August 30, 2023 - Series contributions include discussions on medical error statistics and outpatient surgery rankings. … An abdominal x-ray confirmed a large amount of stool in the colon with no free air and her blood leukocyte … the surgeon found stercoral colitis and a large perforated “stercoral ulcer” of the proximal sigmoid colon
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psnet.ahrq.gov/issue/good-medical-care-can-suffer-late-day
December 16, 2020 - November 11, 2015
Exclusion of residents from surgery-intensive care team communication … July 8, 2015
Characterising 'near miss' events in complex laparoscopic surgery through … August 10, 2019
WebM&M Cases
Anemia and Delayed Colon
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - cholelithiasis”, prescriptions for ondansetron and hydrocodone/acetaminophen, and an outpatient referral to general … surgery. … obstruction secondary to adhesions occurs in approximately 15% of patients with previous abdominal surgery … , Division of Trauma, Acute Care Surgery, and Surgical Critical Care UC Davis Health ghutter@ucdavis.edu … Colonoscopy after CT diagnosis of diverticulitis to exclude colon cancer: a systematic literature review
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psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
April 03, 2024 - hospital with abdominal pain and diagnosed with a bowel obstruction, secondary to a new diagnosis of colon … She underwent an uncomplicated surgical resection of the colon cancer with relief of the obstruction. … From the Same Author(s)
Characteristics and contributing factors of diagnostic error in surgery
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psnet.ahrq.gov/node/49533/psn-pdf
March 01, 2007 - ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery. … need for gram-negative bacterial
coverage in antibiotic prophylaxis for oncological head and neck surgery
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - cholelithiasis”, prescriptions for ondansetron and hydrocodone/acetaminophen,
and an outpatient referral to general … surgery. … several red flags that were ignored or minimized in this case, including the history of
abdominal surgery … , Division of Trauma, Acute Care Surgery, and Surgical Critical Care
UC Davis Health
ghutter@ucdavis.edu … Colonoscopy after CT diagnosis of diverticulitis to exclude colon
cancer: a systematic literature review
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - cholelithiasis”, prescriptions for ondansetron and hydrocodone/acetaminophen, and an outpatient referral to general … surgery. … obstruction secondary to adhesions occurs in approximately 15% of patients with previous abdominal surgery … patients who underwent operative management for small bowel obstruction had previous abdominopelvic surgery … Colonoscopy after CT diagnosis of diverticulitis to exclude colon cancer: a systematic literature review
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psnet.ahrq.gov/node/49548/psn-pdf
October 01, 2007 - (CT)
scan of the abdomen with iodinated contrast was done, which revealed a normal appendix and a colon … Thyrotoxicosis or thyroid storm may be precipitated by a number of clinical stressors including
surgery
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psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
November 13, 2024 - Her liver function worsened, and she developed pseudo-obstruction of her colon (Ogilvie syndrome) requiring … 2019
Predictive power of the "trigger tool" for the detection of adverse events in general … surgery: a multicenter observational validation study.
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psnet.ahrq.gov/periodic-issue/periodic-issue-420
November 29, 2023 - sought to understand how outpatient providers (i.e., primary care, dentists, dermatology, orthopedic surgery … sought to understand how outpatient providers (i.e., primary care, dentists, dermatology, orthopedic surgery … selected a jug of dialysis liquid rather than a polyethylene glycol solution commonly used to clean the colon
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psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - tomography (CT) scan of the abdomen with iodinated contrast was done, which revealed a normal appendix and a colon … Thyrotoxicosis or thyroid storm may be precipitated by a number of clinical stressors including surgery
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psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
November 21, 2021 - BMC Surgery. 2014;14:96. [go to PubMed] 16. … November 21, 2021
WebM&M Cases
Wrong Turn through Colon