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7841. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia | PSNet
      psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
      January 29, 2021 - These providers will then no longer be available to staff elective surgery operating rooms during the … WebM&M Cases Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery … Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery

7842. In Conversation With… Thomas J. Nasca, MD, MACP | PSNet
      psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
      July 10, 2024 - heart, and two investigator-initiated trials are now underway, one in internal medicine and one in general … surgery, to try to understand whether parsing the rules beyond those core three or four basic ones has … [Editor's note: Since this interview was conducted, one of the studies , in surgery, was published in

7843. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-308
      September 29, 2021 - Commentary Quality and safety in surgery: challenges and opportunities. … recent history of interferon treatment for Hepatitis C infection and a remote history of cervical spine surgery

7844. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-354
      August 05, 2022 - Study Adverse events in infants less than 6 months of age after ambulatory surgery … This retrospective study of infants less than 6 months of age admitted for ambulatory surgery found that

7845. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-407
      September 27, 2023 - Commentary How does robotic-assisted surgery change OR safety culture? … A first-year orthopedic surgery resident was consulted to aspirate fluid from the left ankle of a patient

7846. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-375
      December 14, 2022 - anesthesiologist, the patient was trying to communicate to him that she had undergone jaw replacement surgery … During extubation after surgery, the anesthesia care provider noticed a large (approximately 4-5 cm)

7847. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-373
      December 14, 2022 - anesthesiologist, the patient was trying to communicate to him that she had undergone jaw replacement surgery … During extubation after surgery, the anesthesia care provider noticed a large (approximately 4-5 cm)

7848. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-399
      July 31, 2023 - Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery … The most frequent never events were wrong site or wrong patient surgery, wrong surgical procedure, and

7849. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-424
      January 04, 2024 - authors present 15 perioperative near-miss events (e.g., medication administration errors, wrong-site surgery … Newspaper/Magazine Article Shining a glaring light on surgery: technology that

7850. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-428
      February 28, 2024 - Use of professional interpreters for patients with limited English proficiency undergoing surgery … Month’s WebM&Ms WebM&M Cases Airway Obstruction during Anterior Cervical Spine Surgery

7851. Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax | PSNet
      psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
      December 14, 2022 - After careful evaluation, the patient underwent video-assisted thoracoscopic surgery (VATS) pleurodesis … After surgery, the patient required about 2 liters/minute of oxygen by nasal cannula to prevent dyspnea

7852. Central Line Clot | PSNet
      psnet.ahrq.gov/web-mm/central-line-clot
      August 04, 2021 - October 21, 2015 Perioperative safety in plastic surgery: is the World Health Organization … Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery

7853. Breakage of a PICC Line | PSNet
      psnet.ahrq.gov/web-mm/breakage-picc-line
      June 21, 2023 - The child described in the present case required surgery for removal of the PICC fragment. … Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery

7854. Liver Biopsy: Proceed With Caution | PSNet
      psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
      March 07, 2012 - Finally, while liver biopsy can be performed in essentially any location, ranging from an outpatient surgery … Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery

7855. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33769/psn-pdf
      June 01, 2014 - In the 1970s and 1980s, events like the 1975 Congressional hearings on unnecessary surgery and ABC's … Getting Ready for National Health Insurance: Unnecessary Surgery.

7856. More Treatment—Better Care? | PSNet
      psnet.ahrq.gov/web-mm/more-treatment-better-care
      August 11, 2021 - Decision aids and breast cancer: do they influence choice for surgery and knowledge of treatment options … Involving patients in clinical decisions: impact of an interactive video program on use of back surgery

7857. Root Cause Analysis Gone Wrong | PSNet
      psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
      August 28, 2024 - The surgery was uneventful, and the transplanted kidney was connected successfully. … RCAs over an 8-year period showed that similar adverse events (such as retained foreign objects during surgery

7858. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room | PSNet
      psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
      July 28, 2021 - May 1, 2009 View More See More About The Topic Outpatient Surgery

7859. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74251/psn-pdf
      January 26, 2022 - Gary Raff, MD Chief, Division of Pediatric Cardiothoracic Surgery https://psnet.ahrq.gov//#15 Co-Chair … Prospective analysis of percutaneous central venous catheterization in infants <4.0 kg undergoing cardiac surgery

7860. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60173/psn-pdf
      March 30, 2020 - For example, do we need to still look at wrong site surgery?