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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - After induction of general anesthesia, the assistant surgeon tried 10 times to cannulate either subclavian … Unfortunately, the surgeon had damaged an intercostal artery when he inserted the chest tube emergently … The next issue the surgeon had to address was choosing a surgical approach that would be most appropriate … Additionally, in this case, the surgeon damaged an intercostal artery while inserting the chest tube … At such a pre-procedure pause, the surgeon has an opportunity to communicate anticipated risks of the
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psnet.ahrq.gov/issue/association-overlapping-surgery-increased-risk-complications-following-hip-surgery
November 21, 2021 - After adjustment for factors known to predict surgical outcomes, such as hospital and surgeon case volume … September 23, 2020
Association of surgeon-patient sex concordance with postoperative … September 21, 2022
Association of surgeon-patient sex concordance with postoperative
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psnet.ahrq.gov/web-mm/good-catch-operating-room
June 14, 2017 - The procedure initially started well and the surgeon followed his expected operative plan. … Since the surgeon did not notice excessive bleeding, he initially continued with the procedure. … Although the surgeon was surprised by the anesthesiologist's forcefulness, he recognized her concern, … A vascular surgeon was urgently consulted. … Critical role of the surgeon–anesthesiologist relationship for patient safety.
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psnet.ahrq.gov/node/49427/psn-pdf
January 01, 2004 - In the recovery room, the surgeon discussed the changes to the planned procedure with the patient's wife … ,
who informed the surgeon that the patient's right testicle had been removed after a traumatic injury … Likewise, it would
be helpful to have information about the extent to which the operating surgeon was … Wrong-site Surgery and Other Cognitive Errors
In this case, the surgeon almost certainly never considered … In this anachronistic model, the non-surgeon
physician, resident, nurse, and technician team members
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psnet.ahrq.gov/issue/six-things-every-plastic-surgeon-needs-know-about-teamwork-training-and-checklists
September 07, 2016 - Image/Poster
Six things every plastic surgeon needs to know about teamwork training … Six things every plastic surgeon needs to know about teamwork training and checklists. … Six things every plastic surgeon needs to know about teamwork training and checklists.
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psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - He notified the surgeon. … The surgeon
replied, "You’ll find it on your table somewhere," and continued to attain hemostasis and … The nurse notified the surgeon that he believed the suction
tip catheter was inside the patient. … If so, this error may actually have resulted from actions taken by a single individual (the
surgeon) … Perhaps the surgeon doubted the nurse’s suggestion that the tip
was in the chest cavity, and thus at
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psnet.ahrq.gov/issue/deficiencies-community-care-network-credentialing-process-former-va-surgeon-and-veterans
November 29, 2023 - Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon … Citation Text:
Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon … Citation Text:
Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - The procedure initially started well and the surgeon followed his
expected operative plan. … Since the surgeon did not notice
excessive bleeding, he initially continued with the procedure. … The anesthesiologist was very concerned about the patient and said to the surgeon, "I think we have an … A vascular surgeon was urgently
consulted. … Critical role of the surgeon–anesthesiologist relationship for patient safety.
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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - Before discharge, the surgeon instructed her to return in 10 days for suture removal. … The surgeon also
told the patient not to soak her hand in water, which would reduce the risk of infection … The MA did not document each call but reportedly discussed each
call with the surgeon. … One day later, the patient
called and asked to see the surgeon, but she was denied because the MA said … At that appointment, the surgeon
recommended immediate surgery to treat the infection.
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - In the recovery room, the surgeon discussed the changes to the planned procedure with the patient's wife … , who informed the surgeon that the patient's right testicle had been removed after a traumatic injury … Likewise, it would be helpful to have information about the extent to which the operating surgeon was … Wrong-site Surgery and Other Cognitive Errors
In this case, the surgeon almost certainly never considered … In this anachronistic model, the non-surgeon physician, resident, nurse, and technician team members
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psnet.ahrq.gov/node/837347/psn-pdf
June 08, 2022 - Surgeon General’s Advisory on Building a Thriving Health Workforce. … Washington DC:
Office of the Surgeon General; May 2022.
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psnet.ahrq.gov/glossary/swiss-cheese-model
September 13, 2021 - conventions for identifying sidedness on radiology tests, a protocol for signing the correct site when the surgeon … The surgeon may meet the patient for the first time in the operating room. … A hurried x-ray technologist might mislabel a film (or simply hang it backwards and a hurried surgeon
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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - health records but
without seeing the patient, who was in another hospital, the anesthetist asked the surgeon … After induction of general anesthesia, the assistant surgeon tried 10 times to cannulate either
subclavian … Unfortunately, the surgeon had damaged an intercostal artery when he inserted the chest tube emergently … Additionally, in this case, the surgeon damaged an intercostal artery while inserting the chest tube … A
preoperative discussion between the attending surgeon and the trainee regarding anticipated risks
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - The day following the surgery, the pathologist contacted the surgeon to report no evidence of cancer. … The surgeon then reviewed the initial CT scan and realized his mistake. … Once the surgeon decided he did not need the imaging to proceed with surgical treatment, the proverbial … Either way, the surgeon would have been given the opportunity to review the imaging and identify the … The surgeon moves down one level and completes the procedure appropriately. Table 2.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
October 01, 2003 - As the trainee prepared to make an incision on the left side of the vulva, the attending surgeon stopped … by senior staff members
Responses differed by profession (% “yes”):
Airline pilot response: 97%
Surgeon … The surgeon denied that any error had been made; he insisted that the original biopsies had been mislabeled … The surgeon did not inform the patient of the error. … .): Wrong Side Surgery
When the patient returned for routine follow-up, the surgeon performed a vulvar
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psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
August 05, 2009 - Upon examination of the knee under anesthesia and with visualization from the arthroscope, the surgeon … After the surgery, the surgeon briefed the patient in the post-anesthesia care unit (PACU) on his findings … When the husband picked up the patient, the written discharge instructions from the surgeon were generic … The confusion was never discovered at two subsequent postop visits, in part because the surgeon never … When she experienced significant pain, she called the surgeon who then chastised her for not following
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psnet.ahrq.gov/node/852805/psn-pdf
August 23, 2023 - This news feature reports
on systemic flaws that enabled a vascular surgeon with questionable business … unstoppable-doctor-has-been-investigated-every-level-government-how-he-still-practicing
https://psnet.ahrq.gov/issue/surgeon-so-bad-it-was-criminal
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - As the trainee prepared to make an incision on the left side of the vulva, the attending surgeon stopped … Typically, guidelines require the marking and signing of the surgical site by the operative surgeon ( … The wrong site surgery occurred because the surgeon remembered, incorrectly, that he had biopsied the … The attending surgeon denied that any error had been made; he insisted that the original biopsies had … The surgeon did not inform the patient of the error.
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - When requested by the attending surgeon, the scrub technician verbally confirmed the medication (“ICG … in D50”) being handed to the surgeon. … The surgeon injected the medication to stain the eye. … The nurse correctly read the label in the presence of the surgeon, who may have been distracted, and … distract the surgeon during that time.
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psnet.ahrq.gov/cme
February 26, 2025 - to move but recalls making a “monumental effort” to utter a small groaning noise, which alerted the surgeon … She heard the surgeon verbally acknowledge her condition and offer reassurance that the operation was … During the first follow-up visit, the surgeon did not address the situation, so the patient brought it … The surgeon seemed surprised and embarrassed that the patient remembered waking up during the operation … Each time, the surgeon ordered hetastarch for volume expansion.