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psnet.ahrq.gov/issue/burden-healthcare-utilization-cost-and-mortality-associated-select-surgical-site-infections
October 09, 2024 - impact of SSI infections after coronary artery bypass graft (CABG), bariatric surgery (BS), or certain orthopedic … Patients with SSI after orthopedic procedures had significantly higher 12-month mortality compared to
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - Orthopedics considered the fracture stable based on post-mobilization x-rays. … Cardiology, Cardiothoracic Surgery, Trauma Surgery, and Orthopedics discussed this high-risk case extensively … The trauma surgery team and orthopedic consultant were correct to adopt a deliberate and conservative … An experienced orthopedic surgeon – and this case should have been performed by the most experienced … Surgery
Surgical Complications
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psnet.ahrq.gov/node/44165/psn-pdf
May 27, 2015 - could be utilized as a trigger for detecting errors, this study assessed rates of such incidents in an
orthopedic … similar to prior studies of delayed
diagnosis, researchers examined a retrospective case series of orthopedic
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - Four months later, the orthopedic surgeon ordered a
routine follow-up X-ray of the left shoulder. … This report along with the images were sent to the
orthopedic surgeon’s office the same day. … However, the orthopedic surgeon independently read and
interpreted the same images as “slight loss of … The patient saw the orthopedic surgeon multiple times after the initial follow-up X-ray without any … In this case, the orthopedic surgeon did not have training in interpreting chest imaging findings, and
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - The orthopedic surgeon, recognizing the risk of deep vein thrombosis (DVT), prescribed enoxaparin (Lovenox … Orthopedic surgery patients are a special focus of most guidelines, since such patients are at extremely … developed spinal hematoma after receiving LMWH around the time of neuraxial anesthesia, most commonly for orthopedic … surgery. … Conversely, the orthopedic surgeon may not have known the anesthesiologist was planning on neuraxial
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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - diagnosed with a rotator cuff injury and
underwent left shoulder surgery
• Four months later, the orthopedic … evaluation”
5
Case Details
• The radiologist’s report along with the images were sent to the
orthopedic … surgeon’s office the same day
• The orthopedic surgeon independently read and interpreted
the same … was no mention of the soft tissue density nor was any
follow-up study ordered
• The patient saw the orthopedic … such as surgery
13
“What We’ve Got Here is a Failure to Communicate” (3)
• In this case, the orthopedic
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psnet.ahrq.gov/issue/root-cause-analysis-and-actions-prevention-medical-errors-quality-improvement-and-resident
October 19, 2016 - Orthopedics. 2017;40(4):e628-e635. doi:10.3928/01477447-20170418-04. … Orthopedics . 2017; 40 (4) :e628-e635 .
View more articles from the same authors. … Orthopedics. 2017;40(4):e628-e635. doi:10.3928/01477447-20170418-04.
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psnet.ahrq.gov/issue/healthcare-simulation-nursing-practice
July 08, 2020 - January 23, 2019
Quality, Value, and Patient Safety in Orthopedic Surgery.
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - The Case An orthopedic surgeon at a small community hospital contacted an emergency department (ED) … The orthopedic surgeon briefly described a 92-year-old woman with a history of dementia who had a left … The referring orthopedic surgeon also spoke with the on-call orthopedic surgery resident at the tertiary … She was quickly admitted by the orthopedic surgery resident and prepped for surgery the following morning … Although it was not completely clear to the orthopedic team or anesthesiologists what happened, all agreed
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - primary team, with involvement from
Nephrology, Cardiology and General Internal Medicine
services
• Orthopedics … osteopenia secondary to renal osteodystrophy
• Cardiology, Cardiothoracic Surgery, Trauma Surgery, and
Orthopedics … cases,
the evident frailty of this patient was a cause for concern and
the trauma surgery team and orthopedic … thin.
16
Approach to Improving Safety (3)
• Procedure itself was complicated - an experienced orthopedic
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psnet.ahrq.gov/issue/management-operating-room-critical-events
March 27, 2024 - March 11, 2020
Quality, Value, and Patient Safety in Orthopedic Surgery.
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psnet.ahrq.gov/issue/antimicrobial-stewardship
October 24, 2018 - Related Resources From the Same Author(s)
Quality, Value, and Patient Safety in Orthopedic … Surgery.
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psnet.ahrq.gov/issue/perioperative-issues-surgeons-improving-patient-safety-and-outcomes
September 19, 2018 - June 30, 2010
Quality, Value, and Patient Safety in Orthopedic Surgery.
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psnet.ahrq.gov/issue/simulation-otolaryngology
January 23, 2019 - August 14, 2024
Quality, Value, and Patient Safety in Orthopedic Surgery.
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psnet.ahrq.gov/issue/pediatric-quality
December 06, 2011 - August 21, 2019
Quality, Value, and Patient Safety in Orthopedic Surgery.
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psnet.ahrq.gov/issue/patient-safety-22
November 26, 2008 - May 29, 2019
Quality, Value, and Patient Safety in Orthopedic Surgery.
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psnet.ahrq.gov/issue/wrong-site-surgery-california-2007-2014
July 27, 2023 - Orthopedic surgery accounted for 35% of the cases reported.
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psnet.ahrq.gov/issue/pain-alleviation-toolkit
April 22, 2020 - See More About The Topic
Operating Room
Physicians
Patients
Anesthesiology
Orthopedic … Surgery
View More
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psnet.ahrq.gov/issue/complications-and-errors-periodontal-and-implant-therapy
May 29, 2019 - August 7, 2019
Quality, Value, and Patient Safety in Orthopedic Surgery.
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - The patient was seen in the Orthopedics clinic one month after his transfer to the SNF. … SNF with orders to receive an additional four weeks of intravenous antibiotics with follow up in the Orthopedics … The patient was seen in the Orthopedics clinic 3.5 weeks after discharge, still on intravenous antibiotics … not experience any adverse effects and no signs of infection were noted when he followed-up with the Orthopedic … This patient was seen for follow-up in the Orthopedic Clinic, but laboratory results were not available