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- Care Coordination(1)
- Communication Improvement(8)
- Computerized Decision Support(1)
- Computerized Provider Order Entry (CPOE)(1)
- Culture of Safety(1)
- Education and Training(10)
- Error Reporting and Analysis(18)
- Human Factors Engineering(15)
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- Logistical Approaches(4)
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A 63-year-old woman was admitted to a hospital for anterior cervical discectomy (levels C4-C7) and plating for cervical spinal stenosis under general anesthesia. The operation was uneventful and intraoperative neuromonitoring was used to help prevent spinal cord and peripheral nerve injury. During extubation after surgery, the anesthesia care provider noticed a large (approximately 4-5 cm) laceration on the underside of the patient’s tongue, with an associated hematoma.
Boodman SG. Washington Post. January 23, 2021.
A 73-year-old female underwent a craniotomy and aneurysm clipping to resolve a subarachnoid hemorrhage due to a ruptured aneurysm. The neurosurgery resident confirmed the presence of neuromonitoring with the Operating Room (OR) front desk but the neuromonitoring technician never arrived and the surgeon – who arrived after the pre-op huddle – decided to proceed with the procedure in their absence. Although no problems were identified during surgery, the patient emerged from anesthesia with left-sided paralysis, and post-op imaging showed evidence of a new stroke.