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psnet.ahrq.gov/issue/awareness-human-factors-operating-theatres-during-covid-19-pandemic
October 27, 2021 - Patient Safety Innovations
There is an app for that: mobile technology improves complication
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psnet.ahrq.gov/issue/surgical-site-infection-prevention-review
February 15, 2023 - Patient Safety Innovations
There is an app for that: mobile technology improves complication
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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/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/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/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
September 01, 2007 - The goal is to present to the division or department a well-planned analysis of a medical error or complication … It is logical to assume that a resident, if exposed to a complication or error in an educationally meaningful … manner early in his career, will be less likely to create that complication as his career progresses … Moreover, if that complication arises, he will be more likely to detect it earlier and to treat it more … We have now seen several examples of effective things you can do that really change complication rates
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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/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/issue/association-between-surgeon-stress-and-major-surgical-complications
November 29, 2023 - Study
Association between surgeon stress and major surgical complications.
Citation Text:
Awtry J, Skinner S, Polazzi S, et al. Association between surgeon stress and major surgical complications. JAMA Surg. 2025;160(3):332-340. doi:10.1001/jamasurg.2024.6072.
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psnet.ahrq.gov/issue/complications-surgery-root-cause-analysis-and-preventive-measures
November 24, 2021 - Commentary
Complications in surgery: root cause analysis and preventive measures.
Citation Text:
Chung KC, Kotsis S. Complications in surgery: root cause analysis and preventive measures. Plast Reconstr Surg. 2012;129(6):1421-1427. doi:10.1097/PRS.0b013e31824ecda0.
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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/33675/psn-pdf
October 01, 2008 - In our early work in assessing interrater reliability of determining the timing of an illness or
complication … Romano and colleagues (15) found that half of the difference in postoperative
(after back surgery) complication … Can administrative data be used to compare
postoperative complication rates across hospitals?
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psnet.ahrq.gov/node/49713/psn-pdf
June 01, 2014 - complications in some hospitals.(16)
Take-Home Points
CVC-associated air embolism is a preventable complication … Neurologic manifestations of
cerebral air embolism as a complication of central venous catheterization … The CVC removal distress syndrome: an unappreciated
complication of central venous catheter removal.
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Surgical Quality Improvement Program (NSQIP) registry found that 78% of patients with any postdischarge complication … , 12% of patients with only in-hospital complications, and 5% of patients without any in-hospital complication … Use of the NSQIP complication risk index may allow prospective identification of patients at high risk
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psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - Autonomic dysreflexia as a complication of a fecal management system in a man with tetraplegia. … Significant rectal bleeding as a complication of a fecal collecting device: report of a case. … 13, 2022
WebM&M Cases
Primary Workaround, Secondary Complication
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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/opioids-prescribed-after-low-risk-surgical-procedures-united-states-2004-2012
May 29, 2024 - RIS
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Related Resources From the Same Author(s)
Complication
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psnet.ahrq.gov/issue/exploratory-analysis-association-between-healthcare-associated-infections-hospital-financial
June 12, 2024 - September 26, 2018
Complication rates, hospital size, and bias in the CMS Hospital-Acquired
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psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
January 19, 2016 - 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/issue/patient-safety-practices-leaders-can-turn-barriers-accelerators
September 07, 2011 - Patient Safety Innovations
There is an app for that: mobile technology improves complication