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psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
April 28, 2021 - three-dimensional conceptualization of the spatial relationships between the organs, instruments, and the tissue … In laparoscopy, however, the supervisor can neither feel the tissue resistance nor control the force … excessive resistance to trocar insertion by inadequately sized incisions leading to increased subcutaneous tissue … developed with a conical, non-cutting tip and others with a radial expandable tip that pushes through the tissues
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psnet.ahrq.gov/node/42920/psn-pdf
February 05, 2014 - This study quantified communication errors between pathologists and surgeons regarding intraoperative
tissue
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psnet.ahrq.gov/node/837215/psn-pdf
July 08, 2022 - The 1996 Food and Drug Administration approval of alteplase (a
recombinant tissue plasminogen activator … the brain to remove cerebral
clots in the hope of saving ischemic but not yet infarcted penumbral tissue … evaluated for endovascular stroke treatment that might have
saved ischemic, but not yet infarcted, brain tissue … ], 21–44%).3
The DEFUSE 3 trial used perfusion imaging to select patients with sufficient ischemic tissue … that was not
yet infarcted (penumbra), relative to tissue that was already infarcted (core), for mechanical
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
December 01, 2014 - intracerebral hemorrhages occur within 24–36 hours of rtPA administration (as in this case)
11
Tissue … Time to treatment with recombinant tissue plasminogen activator and outcome of stroke in clinical practice … times and facilitate the best possible outcomes for ischemic stroke patients treated with recombinant tissue-type
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psnet.ahrq.gov/node/46723/psn-pdf
April 12, 2019 - compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Radiation proctitis is associated with chronic microvascular obliteration resulting in ischemic tissue … The affected tissue demonstrates markedly compromised integrity and impaired wound healing, which dramatically … Take Home Points
Pelvic radiation therapy increases the risk for adjacent tissue injury and can be … WebM&M Cases
Delayed Management of Necrotizing Soft Tissue
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psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
August 31, 2022 - The 1996 Food and Drug Administration approval of alteplase (a recombinant tissue plasminogen activator … of the brain to remove cerebral clots in the hope of saving ischemic but not yet infarcted penumbral tissue … evaluated for endovascular stroke treatment that might have saved ischemic, but not yet infarcted, brain tissue … , 21–44%). 3 The DEFUSE 3 trial used perfusion imaging to select patients with sufficient ischemic tissue … that was not yet infarcted (penumbra), relative to tissue that was already infarcted (core), for mechanical
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - The radiologist interpreted the film as a normal left shoulder
radiograph but noted a “… soft tissue … The surgeon did not mention any soft tissue density, did not
reference the radiologist’s report, and … multiple times after the initial follow-up X-ray without any
knowledge of or follow-up for the “soft tissue … As the abnormal finding of a “soft tissue density in the left suprahilar region” was
attributed to a
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psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - Nevertheless, the patient later required re-operation to excise
necrotic muscle tissue leading to a … Both cases represent failures of timely diagnosis and intervention; permanent loss of muscle
tissue … Cellular
anoxia and tissue necrosis follow if intervention is delayed. … Timely fasciotomy relieves the
intracompartmental pressure and restores perfusion to the affected tissues … to intervene still exists, or that CS has progressed such that ischemia is irreversible and muscle
tissue
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psnet.ahrq.gov/issue/nature-adverse-events-dentistry
November 01, 2023 - 1.4% had experienced an adverse event, most of which were mild or moderate and involved pain or hard tissue
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psnet.ahrq.gov/web-mm/recurrent-appendicitis
January 15, 2020 - that two other surgeons came into the OR to confirm that the appendix was removed with no retained tissue … When she examined the specimen, she found no appendiceal tissue. … ) instead of the actual appendix.( 11 ) This last scenario could explain the absence of appendiceal tissue
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - The team administered intravenous tPA [tissue plasminogen activator] for presumed ischemic
stroke 100 … with time to treatment in acute ischemic stroke patients treated
with intravenous rtPA [recombinant tissue … Tissue plasminogen activator for acute ischemic stroke. … Time to treatment with recombinant tissue plasminogen
activator and outcome of stroke in clinical practice … Review of tissue plasminogen activator, ischemic stroke, and potential legal
issues.
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psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
April 29, 2020 - The physical examination triggered concern about a necrotizing soft tissue infection. … The use of a video visit for wound care is possible as skin and wound tissue can be adequately evaluated … more information, it is difficult to discern whether the caregiver was, in fact, referring to perianal tissue … )
WebM&M Cases
Delayed Management of Necrotizing Soft Tissue
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psnet.ahrq.gov/issue/how-well-do-we-communicate-comparison-intraoperative-diagnoses-listed-pathology-reports-and
May 29, 2019 - study quantified communication errors between pathologists and surgeons regarding intraoperative tissue
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psnet.ahrq.gov/issue/promethazine-conundrum-iv-can-hurt-more-im-injection
November 13, 2018 - This article describes instances of tissue injury as a result of the misadministration of Promethazine
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psnet.ahrq.gov/node/73549/psn-pdf
July 28, 2021 - to direct injection into a blood vessel or,
more commonly, due to rapid systemic uptake from soft tissue … In general, the speed of
absorption is related to the vascularity of the tissue into which the local … Intralipid reverses LAST by increasing
the removal of local anesthetic from affected tissues (e.g.,
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psnet.ahrq.gov/issue/long-term-care-healthcare-associated-infections-2023-analysis-23970-reports
July 08, 2020 - Pennsylvania Patient Safety Reporting System (PA-PSRS), infection rates increased for skin and soft tissue
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - The team administered intravenous tPA [tissue plasminogen activator] for presumed ischemic stroke 100 … with time to treatment in acute ischemic stroke patients treated with intravenous rtPA [recombinant tissue … Tissue plasminogen activator for acute ischemic stroke. … Time to treatment with recombinant tissue plasminogen activator and outcome of stroke in clinical practice … Review of tissue plasminogen activator, ischemic stroke, and potential legal issues.
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psnet.ahrq.gov/issue/value-inking-breast-cores-reduce-specimen-mix
January 14, 2011 - The authors describe a tissue specimen marking mechanism that helped identify discrepancies that could
-
psnet.ahrq.gov/node/846127/psn-pdf
March 15, 2023 - Radiation proctitis is associated with chronic microvascular obliteration resulting in ischemic tissue … The affected tissue demonstrates markedly compromised integrity and impaired wound
healing, which dramatically … Take Home Points
Pelvic radiation therapy increases the risk for adjacent tissue injury and can be associated