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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/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/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/843736/psn-pdf
February 01, 2023 - Serious complications related to obstetric anesthesia: the
serious complication repository project of
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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/sites/default/files/import/webmm.ahrq.gov.278_slideshow.ppt
September 01, 2012 - soft-tissue infections
Peripheral IV catheter–related bacteremia is rare (0.1% of cases) but can be a serious complication … The patient ultimately recovered and was discharged to home.
11
12
Unfortunate Complication
This
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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/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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psnet.ahrq.gov/node/49524/psn-pdf
November 01, 2006 - the anesthesiologist recommended simple observation of the neck,
apparently believing that an airway complication
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psnet.ahrq.gov/web-mm/dont-bite-your-tongue
September 18, 2024 - Background
Oropharyngeal injuries are a known complication of airway management during procedures … 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/issue/association-postoperative-readmissions-surgical-quality-using-delphi-consensus-process
September 25, 2018 - June 10, 2009
Changes in prognosis after the first postoperative complication.
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - Even though IO access devices have a low complication rate, they are substantially more costly (often … The complication rate associated with IO use is small and comparable to IV access. … Complication with intraosseous access: Scandinavian users'
experience.
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - awakenings, and encouraging mobility. 16-19
Approaches to Improving Patient Safety
Beyond the direct complication … The underlying cause was a serious complication of a relatively simple procedure that is commonly performed … The impact of the complication was compounded by lapses in communication between nursing staff and other … A case report of esophageal perforation: Complication of nasogastric tube placement.
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psnet.ahrq.gov/issue/race-postoperative-complications-and-death-apparently-healthy-children
August 10, 2022 - Study
Classic
Race, postoperative complications, and death in apparently healthy children.
Citation Text:
Nafiu OO, Mpody C, Kim SS, et al. Race, postoperative complications, and death in apparently healthy children. Pediatrics. 2020;146(2):e20194113. doi:10.154…
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psnet.ahrq.gov/node/846171/psn-pdf
July 26, 2022 - awakenings, and encouraging mobility.16-19
Approaches to Improving Patient Safety
Beyond the direct complication … The underlying
cause was a serious complication of a relatively simple procedure that is commonly performed … The
impact of the complication was compounded by lapses in communication between nursing staff and other … A case report of esophageal perforation: Complication of nasogastric
tube placement.
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psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
July 02, 2011 - was faced with balancing the risk of re-rupture versus the benefit of possibly detecting an ischemic complication
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psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
May 01, 2017 - obstruction, and necrotizing fasciitis.( 12 ) This patient had an uncommon, but well described PEG complication … : placement of the PEG tube through the colon leading to a gastrocolocutaneous fistula.( 14 ) This complication … 2019
WebM&M Cases
Primary Workaround, Secondary Complication
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psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - been done in a timely fashion, it is likely that the patient would not have
experienced the secondary complication … The more staff members are aware of a potential complication, the
greater the chances of its prevention … Pneumothorax is a rare complication of thoracic central venous catheterization in community EDs.
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - would necessitate a chart review and further investigation that could have potentially prevented the complication … Lack of knowledge may also have contributed to this complication. … Shearing of catheters is an underappreciated complication of spinal drain placement and removal.( 7 ) … Commonly cited reasons in the literature for this complication include withdrawing the catheter through … Perhaps the on-call anesthesiologist had not appreciated this potential complication.
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psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
September 29, 2021 - significant morbidity can occur if the catheter is not inserted correctly or not removed promptly once a complication … of extravasation inherent to IO lines, it is critical that clinicians and care teams anticipate this complication … Compartment syndrome is a rare but serious complication associated with IO lines. … Intraosseous extravasation complication reports. … Case report of a complication. J Bone Jt Surg . 1993;75(3):428–9. [ Available at ]
Spivey WH.