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www.cpsi.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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patientregistry.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
-
teamstepps.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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cahps.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
-
healthcare411.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
-
talkingquality.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
-
monahrq.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
-
ahrqpubs.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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www.innovations.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
-
www.healthcare411.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
-
www.monahrq.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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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
-
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
-
meps.ahrq.gov/data_files/publications/st484/stat484.pdf
November 01, 2015 - pediatrics (8.2 percent); 3)
obstetrics/gynecology (6.5 percent); 4) ophthalmology (6.7 percent); 5)
orthopedics … These
ranges were somewhat smaller than those for orthopedics ($70–$209), OB/GYN
($56–$200), and dermatology
-
psnet.ahrq.gov/issue/pediatric-quality
December 06, 2011 - August 21, 2019
Quality, Value, and Patient Safety in Orthopedic Surgery.
-
psnet.ahrq.gov/issue/patient-safety-22
November 26, 2008 - May 29, 2019
Quality, Value, and Patient Safety in Orthopedic Surgery.
-
psnet.ahrq.gov/issue/antimicrobial-stewardship
October 24, 2018 - Related Resources From the Same Author(s)
Quality, Value, and Patient Safety in Orthopedic … Surgery.
-
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.
-
psnet.ahrq.gov/issue/healthcare-simulation-nursing-practice
July 08, 2020 - January 23, 2019
Quality, Value, and Patient Safety in Orthopedic Surgery.
-
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