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psnet.ahrq.gov/issue/disclosure-and-reporting-surgical-complications-double-edged-sword
December 21, 2014 - Patient Safety Innovations
There is an app for that: mobile technology improves complication
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - TO IMPROVING PATIENT
SAFETY
24
Approaches to Improving Patient Safety (1)
• Beyond the direct complication … • The underlying cause was a serious complication of a relatively simple procedure
that is commonly … – The impact of the complication was compounded by lapses in communication between nursing
staff … A case report of esophageal perforation: Complication of nasogastric tube placement.
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - Understand tracheostomy maintenance and complication-preventive interventions.
3
A Stable Airway? … Comparing the tracheostomy dislodgement and complication rate of non-sutured neck tie to skin sutured
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psnet.ahrq.gov/issue/comparison-appendectomy-outcomes-between-senior-general-surgeons-and-general-surgery
May 03, 2023 - This analysis of medical record data at a single institution compared complication rates following … As measured by a composite score, the complication rate did not differ between trainees and attending
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psnet.ahrq.gov/node/49437/psn-pdf
March 01, 2004 - Review complications of central venous catheterization
Discuss patient and operator factors that affect complication … when sterile precautions are
not followed, and (vi) provide specific feedback to providers with high complication … Central vein catheterization: failure and
complication rates by three percutaneous approaches. … Frequency of Mechanical Complications, According to the Route of Catheterization
Complication Frequency
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psnet.ahrq.gov/node/49715/psn-pdf
August 21, 2014 - Bleeding usually stops within several
minutes (7); however, a feared complication of liver biopsy is … This
stems in part from a large study of post-biopsy monitoring where the complication rates did not … The most common complication after liver biopsy is pain. … Severe abdominal pain should increase the
concern for a significant bleeding complication. … Bleeding complication with liver biopsy: is it predictable?
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psnet.ahrq.gov/issue/compliance-patient-safety-bundle-management-placenta-accreta-spectrum
October 19, 2022 - Placenta accreta spectrum (PAS) is a maternal complication that can result in life-threatening hemorrhage
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psnet.ahrq.gov/issue/medical-error-malpractice-and-complications-moral-geography
August 20, 2018 - Commentary
Medical error, malpractice and complications: a moral geography.
Citation Text:
Zientek DM. Medical error, malpractice and complications: a moral geography. HEC Forum. 2010;22(2):145-57. doi:10.1007/s10730-010-9130-9.
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psnet.ahrq.gov/issue/surgical-complications-and-their-implications-surgeons-well-being
December 04, 2016 - Study
Surgical complications and their implications for surgeons' well-being.
Citation Text:
Pinto A, Faiz O, Bicknell C, et al. Surgical complications and their implications for surgeons' well-being. Br J Surg. 2013;100(13):1748-55. doi:10.1002/bjs.9308.
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psnet.ahrq.gov/issue/effect-hospital-organizational-characteristics-postoperative-complications
December 18, 2017 - Study
The effect of hospital organizational characteristics on postoperative complications.
Citation Text:
Knight M. The effect of hospital organizational characteristics on postoperative complications. J Patient Saf. 2013;9(4):198-202. doi:10.1097/PTS.0b013e3182995e5b.
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psnet.ahrq.gov/node/866395/psn-pdf
July 23, 2024 - the University of Michigan to address failure
to rescue with a particular focus on communication and complication … response to clinical deterioration resulting from an
underlying illness or a medical or surgical care complication … conference by addressing frequent contributors to failure to rescue—poor
communication and insufficient complication … place between August 2018 and August 2020 in a single hospital.1 Myriad clinical cases and surgical
complication … core principles of the RIC—namely,
review of systems, team, and cognitive factors that may impact the complication
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - study, Sidoti et al. showed a higher rate of first pass success, fewer attempts, and overall decreased complication … the excessive number of cannulation attempts in this case is the delay in identifying a known serious complication … More timely identification of this complication, with appropriate intervention (which could have been … This too was an easily preventable complication, given appropriate training and supervision by an attending … American Society of Anesthesiologists. 9 Injury to the intercostal artery is a rare but life-threatening complication
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psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
March 07, 2012 - This stems in part from a large study of post-biopsy monitoring where the complication rates did not … The most common complication after liver biopsy is pain. … Severe abdominal pain should increase the concern for a significant bleeding complication. … Complication rate of percutaneous liver biopsies among persons with advanced chronic liver disease in … Bleeding complication with liver biopsy: is it predictable?
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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Patients who are
recovering well may experience an initial seminal complication (such as an anastomotic … of an underlying illness or a complication of medical care. … mortality with surgery was primarily related to failure to rescue and only weakly
correlated with complication … In contrast, low mortality hospitals were distinguished by how well they "rescued"
patients once a complication … of an underlying illness or a complication of medical care.
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psnet.ahrq.gov/node/46603/psn-pdf
April 12, 2019 - comparison-internal-medicine-and-general-surgery-residents-assessments-
risk-postsurgical
Perioperative complication
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - complications of central venous catheterization Discuss patient and operator factors that affect complication … when sterile precautions are not followed, and (vi) provide specific feedback to providers with high complication … Central vein catheterization: failure and complication rates by three percutaneous approaches. … Frequency of Mechanical Complications, According to the Route of Catheterization Complication
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psnet.ahrq.gov/issue/interpersonal-and-organizational-dynamics-are-key-drivers-failure-rescue
June 18, 2019 - When a patient experiences a major surgical complication, a health care team's inability to prevent
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psnet.ahrq.gov/issue/save-brain-make-checklist
November 02, 2018 - of checklists , this magazine article describes studies that identified benefits , such as reduced complication
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - As a result, the
committee felt the complication might still have occurred even if the radiograph had … For this patient, the chest tube was
placed for spontaneous pneumothorax, a common complication in cystic … Common complications of chest tube placement include malpositioning (the most common complication), … With a functioning chest tube in place, either on water
seal or on suction, such a complication cannot
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psnet.ahrq.gov/node/34779/psn-pdf
December 21, 2014 - incidental approach, uses a multidisciplinary conference format to discuss cases in which a postoperative
complication … The second, a statistical approach, systematically captures annual death and
complication rates for … While presenting tables of
common surgical death and complication rates, the authors suggest that greater