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121. Transfer Troubles | PSNet
     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

122. Around the Block | PSNet
     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

123. Psn-Pdf (pdf file)
     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

124. The Consequences of Miscommunication Regarding a Possible Artifact | PSNet
     psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
     May 11, 2019 - 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 … surgeons towards radiology reports, revealed that the majority of the 200 orthopedic surgeons surveyed … In this case, the orthopedic surgeon did not have training in interpreting chest imaging findings, and

125. Psn-Pdf (pdf file)
     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

126. Spotlight (pdf file)
     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

127. CYP450 Drugs: Expect the Unexpected | PSNet
     psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
     October 19, 2022 - syndromes in HIV/AIDS patients, similar to this case, have been reported in the dermatologic ( 6,7 ), orthopedic … Orthopedics. 2009;32:450. [go to PubMed] 10. … View More See More About The Topic Ambulatory Care Health Care Providers Orthopedic … Surgery Infectious Diseases Medication Errors/Preventable Adverse Drug Events View More

128. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49512/psn-pdf
     May 01, 2006 - The family requested an orthopedic consultation to expedite work-up. … primarily to treat dehydration, it is unlikely that she was admitted directly to the service of the orthopedic … By any reasonable standard of judgment, the orthopedic surgeon committed by far the most serious errors … displaced trimalleolar fracture (at risk for vascular compromise) leave the ED in a splint without an orthopedic … We suspect that the orthopedic surgeon was prompted to review the x-rays in the OR after finally recognizing

129. Healthcare Simulation in Nursing Practice. | PSNet
     psnet.ahrq.gov/issue/healthcare-simulation-nursing-practice
     July 08, 2020 - January 23, 2019 Quality, Value, and Patient Safety in Orthopedic Surgery.

130. Antimicrobial Stewardship. | PSNet
     psnet.ahrq.gov/issue/antimicrobial-stewardship
     October 24, 2018 - Related Resources From the Same Author(s) Quality, Value, and Patient Safety in Orthopedic … Surgery.

131. Perioperative Issues for Surgeons: Improving Patient Safety and Outcomes. | PSNet
     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.

132. Simulation in Otolaryngology. | PSNet
     psnet.ahrq.gov/issue/simulation-otolaryngology
     January 23, 2019 - August 14, 2024 Quality, Value, and Patient Safety in Orthopedic Surgery.

133. Pediatric Quality. | PSNet
     psnet.ahrq.gov/issue/pediatric-quality
     December 06, 2011 - August 21, 2019 Quality, Value, and Patient Safety in Orthopedic Surgery.

134. Patient Safety | PSNet
     psnet.ahrq.gov/issue/patient-safety-22
     November 26, 2008 - May 29, 2019 Quality, Value, and Patient Safety in Orthopedic Surgery.

135. Patient Safety and Quality Improvement. | PSNet
     psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-0
     September 27, 2017 - July 11, 2018 Quality, Value, and Patient Safety in Orthopedic Surgery.

136. Management of Operating Room Critical Events. | PSNet
     psnet.ahrq.gov/issue/management-operating-room-critical-events
     March 27, 2024 - March 11, 2020 Quality, Value, and Patient Safety in Orthopedic Surgery.

137. Right? Left? Neither! | PSNet
     psnet.ahrq.gov/web-mm/right-left-neither
     November 16, 2022 - The family requested an orthopedic consultation to expedite work-up. … primarily to treat dehydration, it is unlikely that she was admitted directly to the service of the orthopedic … By any reasonable standard of judgment, the orthopedic surgeon committed by far the most serious errors … displaced trimalleolar fracture (at risk for vascular compromise) leave the ED in a splint without an orthopedic … We suspect that the orthopedic surgeon was prompted to review the x-rays in the OR after finally recognizing

138. Patient Safety. | PSNet
     psnet.ahrq.gov/issue/patient-safety-20
     July 01, 2018 - May 1, 2019 Quality, Value, and Patient Safety in Orthopedic Surgery.

139. Pain Alleviation Toolkit. | PSNet
     psnet.ahrq.gov/issue/pain-alleviation-toolkit
     April 22, 2020 - See More About The Topic Operating Room Physicians Patients Anesthesiology Orthopedic … Surgery View More

140. Complications and Errors in Periodontal and Implant Therapy. | PSNet
     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.