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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - For example, retrospective studies show increased failure and complication rates when multiple access … attempts using the Veress needle method are made (with up to an 80-100% complication rate after more … This complication not only added considerable morbidity to the patient’s postoperative course, but also … resulted in an additional iatrogenic complication: a retained piece of Penrose drain in the wound. … This latter complication could have been avoided by keeping track of the total length of the drain inserted
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - approximately 1 in 150,000 for epidural and 1 in 220,000 for spinal anesthetics.( 7 ) Even though the complication … Although cases also have been reported with unfractionated heparin, the complication is much less common … Spinal hematoma is a rare complication of neuraxial anesthesia, but the risk is increased in patients … 4, 2020
WebM&M Cases
Primary Workaround, Secondary Complication
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psnet.ahrq.gov/node/841468/psn-pdf
December 14, 2022 - Background
Oropharyngeal injuries are a known complication of airway management during procedures requiring … monitoring may minimize the risk of paralysis, which is a catastrophic and
potentially preventable complication … A rare complication of tracheal intubation: tongue perforation.
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psnet.ahrq.gov/node/49753/psn-pdf
February 01, 2016 - more experience are more likely to have clean margins.(7,11,16
) Other studies have documented lower complication … RALP has reported complication
rates (including all grades of perioperative complications, from minor … The reported complication rate related directly to robotic malfunction is very low
(approximately 0.1% … Robotic surgery is generally safe with low overall complication rates, but adding the robot to the
surgical … Positive surgical
margin and perioperative complication rates of primary surgical treatments for prostate
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psnet.ahrq.gov/innovations
February 26, 2025 - the University of Michigan to address failure to rescue with a particular focus on communication and complication … 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
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - Understand tracheostomy maintenance and complication-preventive interventions. … Comparing the tracheostomy dislodgement and complication rate of non-sutured neck tie to skin sutured
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - About six days into the hospitalization, the patient developed clotting problems, a known complication … Our analyses of inter-hospital ECMO transports identified complication rates as
https://psnet.ahrq.gov … checklist applicable to any ECMO-related emergency minimizes the risk of missing any
equipment-related complication
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psnet.ahrq.gov/node/851068/psn-pdf
June 28, 2023 - psnet.ahrq.gov/issue/building-culture-safety-health-care
Healthcare-acquired infections (HAIs) are a common complication
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psnet.ahrq.gov/node/33641/psn-pdf
November 01, 2006 - In the patient safety field, the term "expected complication" is both defeatist and ultimately self-fulfilling … the tools and concepts of human factors engineering, since these are an
antidote to the "expected complication … Would you have
called this an "expected complication" of the procedure and moved on? … In our old mindset, we could call this frequency the "expected complication
rate" of taking this new
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psnet.ahrq.gov/web-mm/informed-or-misled
April 24, 2018 - anesthesia and suffered the adverse outcome of permanent unilateral hearing loss with tinnitus, an unusual complication … discussion took place; it does not absolve the clinician or the hospital from potential liability if a complication
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psnet.ahrq.gov/issue/sustaining-teamwork-behaviors-through-reinforcement-teamstepps-principles
September 02, 2015 - Poor teamwork in operating rooms is associated with higher postoperative complication and mortality
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psnet.ahrq.gov/issue/cardiac-surgical-icu-care-eliminating-preventable-complications
August 04, 2021 - Review
Cardiac surgical ICU care: eliminating "preventable" complications.
Citation Text:
Shake JG, Pronovost P, Whitman GJR. Cardiac surgical ICU care: eliminating "preventable" complications. J Card Surg. 2013;28(4):406-13. doi:10.1111/jocs.12124.
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psnet.ahrq.gov/issue/identifying-and-reducing-complications-after-emergency-room-discharge
May 25, 2022 - Newspaper/Magazine Article
Identifying and reducing complications after emergency room discharge.
Citation Text:
Identifying and reducing complications after emergency room discharge. Hofmann PB, Bagian JP. Patient Saf Qual Healthc. February 20, 2017.
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psnet.ahrq.gov/issue/human-error-not-communication-and-systems-underlies-surgical-complications
November 18, 2020 - Study
Human error, not communication and systems, underlies surgical complications.
Citation Text:
Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144(4):557-63; discussion 563-5. doi:10.1016/j.surg.2008.06.011.
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psnet.ahrq.gov/issue/surgical-complications-disclosing-adverse-events-and-medical-errors
September 23, 2020 - Commentary
Surgical complications: disclosing adverse events and medical errors.
Citation Text:
Wang AS, Eisen DB. Surgical complications: disclosing adverse events and medical errors. J Am Acad Dermatol. 2013;68(1):144-6. doi:10.1016/j.jaad.2012.09.008.
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psnet.ahrq.gov/issue/opioid-prescribing-patterns-and-complications-dermatology-medicare-population
May 25, 2022 - Study
Opioid prescribing patterns and complications in the dermatology Medicare population.
Citation Text:
Cao S, Karmouta R, Li DG, et al. Opioid Prescribing Patterns and Complications in the Dermatology Medicare Population. JAMA Dermatol. 2018;154(3):317-322. doi:10.1001/jamadermatol.2…
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psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
July 23, 2024 - are single lumen and 75% of which are multi-lumen) experiences annual PICC-related maintenance and complication … ID physician approval of PICC use was associated with lower odds of a PICC-related complication (6.5%
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psnet.ahrq.gov/node/864855/psn-pdf
March 20, 2024 - operating-room-organization-and-surgical-performance-systematic-review
https://psnet.ahrq.gov/issue/surgical-skill-and-complication-rates-after-bariatric-surgery
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psnet.ahrq.gov/node/49724/psn-pdf
January 01, 2015 - However, a surgeon encountering
this complication and lacking in experience in laparoscopic suturing … Bowel injury as a complication of laparoscopy. Br J Surg.
2004;91:1253-1258. [go to PubMed]
2.
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psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - SPOTLIGHT CASE
Beeline to Spine
Citation Text:
Smetana GW. Beeline to Spine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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