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- Care Coordination(1)
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- Computerized Decision Support(1)
- Culture of Safety(9)
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- Error Reporting and Analysis(22)
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- Device-Related Complications(2)
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- Fatigue and Sleep Deprivation(1)
- Identification Errors(2)
- Interruptions and distractions(1)
- Medical Complications(4)
- Medication Safety(11)
- MRI safety(1)
- Psychological and Social Complications(5)
- Surgical Complications(47)
Järvinen TLN, Rickert J, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.
A 52-year-old man complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury and underwent left shoulder surgery. The patient received a routine follow-up X-ray four months later.
A 40-year-old man with multiple comorbidities, including severe aortic stenosis, was admitted for a pathologic pelvic fracture (secondary to osteoporosis) after a fall. During the hospitalization, efforts at mobilization led to a second fracture of the left femoral neck The case describes deviations in the plan for management of anesthesia and postoperative care which ultimately contributed to the patient’s death.
American Society of Anesthesiologists, American Academy of Orthopaedic Surgeons. March 12, 2020.