-
psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - hospital course but was ultimately discharged to a rehabilitation facility with no major permanent injuries … from a cervical laceration that extends beyond the vagina into the peritoneal cavity or a vaginal wall injury
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.2_slideshow.ppt
February 01, 2003 - Neuromuscular blockade overdose
Aminoglycosides or intravenous magnesium
Neurological impairment or injury
-
psnet.ahrq.gov/primer/communication-between-clinicians
September 15, 2024 - October 9, 2013
Patterns of communication breakdowns resulting in injury to surgical
-
psnet.ahrq.gov/node/50931/psn-pdf
February 26, 2020 - Even in the absence of a history suggestive of esophageal perforation
(instrumentation, injury, vomiting … Utter, MD MSc
Professor of Surgery
Division of Trauma, Acute Care Surgery, and Surgical Critical
-
psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
March 31, 2021 - when) treated in a timely and aggressive manner. 1 Rarely, NSTIs can occur as a severe postoperative wound … Wound infections are routinely managed by operating surgeons of all types, but whether an NSTI fits under … If he or she described a ‘wound infection in a plastic surgery patient,’ for example, this would have … Burnout Physician burnout (also referred to as “moral injury”) is an ongoing topic of discussion in medicine … Journal of Trauma and Acute Care Surgery . 2018 July;85(1):208-214.
-
psnet.ahrq.gov/node/49548/psn-pdf
October 01, 2007 - Or the precipitant may be severe
thermal injury, diabetic ketoacidosis, pulmonary thromboembolism, or … precipitated by a number of clinical stressors including
surgery, iodine contrast load, infection, trauma
-
psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
March 01, 2012 - Even this can be problematic because the majority of injuries go uncompensated, and a greater number … Beyond negligence: avoidability and medical injury compensation. Soc Sci Med. 2008;66:387-402. … to always wash their hands before they touch me, but if I come into the emergency room with a stab wound … the patient about what he or she might have done better and how they might have contributed to the injury
-
psnet.ahrq.gov/web-mm/missed-tb
March 03, 2010 - obliterans with organizing pneumonia], Wegner's Granulomatosis) Drug-induced lung injury … October 26, 2010
Clinical handover in the trauma setting: a qualitative study of paramedics … and trauma team members. … January 19, 2011
Trauma resuscitation errors and computer-assisted decision support. … March 2, 2011
Assessing clinical handover between paramedics and the trauma team.
-
psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - That report called out the fact that many physical injuries are happening in the workforce, as well as … psychological injury due to lack of respect, bullying, fear, stress, and productivity pressures.
-
psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
February 26, 2020 - Nevertheless, every patient deserves to be provided with the best opportunity to survive an illness or injury … that permits all necessary interventions to be provided commensurate with the degree of illness or injury … Consulting Editor, AHRQ’s Patient Safety Network (PSNet) Professor Department of Surgery Division of Trauma … 2022
WebM&M Cases
Errors in Managing an Open Wound
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
October 01, 2015 - Case: The Risks of Absent Interoperability
A 47-year-old man with paraplegia (secondary to a gunshot wound … However, the cardiac arrest led to an anoxic brain injury, and he remained in a vegetative state.
6
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
July 01, 2003 - with uncertain outcomes
i.e., successful cardiac resuscitation with resultant severe anoxic brain injury
-
psnet.ahrq.gov/node/33570/psn-pdf
June 15, 2024 - using-medical-malpractice-closed-claims-data-reduce-surgical-risk-and-improve-patient-safety
https://psnet.ahrq.gov/issue/patterns-communication-breakdowns-resulting-injury-surgical-patients
-
psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
April 29, 2020 - Common examples include pneumonia, Clostridium difficile infection, pressure injuries, delirium, and … diarrhea in an incontinent patient with skin breakdown on the “backside” should have raised an alarm, as wound … The use of a video visit for wound care is possible as skin and wound tissue can be adequately evaluated … Wesley Valdes, DO
Telehealth and Wound Specialist
Sacramento, CA
wesley.valdes@gmail.com
Garth
-
psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
January 01, 2024 - after a determination that the
facilities noncompliance with licensing requirements had caused serious injury … responsibility of the surgeon, related to the prevention of retained surgical
items, is to perform a methodical wound … examination before closing the wound to do their part to ensure no
unintended items have been left … Lap Pad Correct Actually 5 laps retained
11 Damage control laparotomy;
2009
Lap Pad Correct Trauma … Takeback for evisceration
after laparotomy for lysis of
adhesions; 2012
Lap Pad Correct Kerlix wound
-
psnet.ahrq.gov/node/72616/psn-pdf
December 22, 2020 - Pain is the most common type of AE
identified, followed by hard tissue damage, nerve injury, and soft
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - the control of the health care professional, patient, or consumer”
Adverse drug event (ADE)
“an injury
-
psnet.ahrq.gov/node/49652/psn-pdf
May 01, 2012 - 1.82 preventable ADEs per admission among non-obstetrical admissions (3), and one error resulting in
injury
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
May 01, 2011 - ICU, he was noted to have fixed and dilated pupils on neurologic exam, a sign of serious neurologic injury
-
psnet.ahrq.gov/node/49739/psn-pdf
August 21, 2015 - should be considered around 14 days of intubation in an adult population to avoid
laryngotracheal injury … one wake–sleep cycle (approximately 24 hours), the tracheostomy is removed
(decannulation) and the wound … An occlusive dressing is placed to prevent
air escape during wound healing.