The PSNet Collection: All Content
Search All Content
These cases describe the rare but dangerous complication of hematoma following neck surgery. The first case involves a patient with a history of spinal stenosis who was admitted for elective cervical discectomy and cervical disc arthroplasty who went into cardiopulmonary arrest three days post-discharge and could not be intubated due to excessive airway swelling and could not be resuscitated. Autopsy revealed a large hematoma at the operative site, causing compression of the upper airway, which was the suspected cause of respiratory and cardiac arrest.
Boston, MA; Institute for Healthcare Improvement: December 2022.
ISMP Medication Safety Alert!: Acute Care Edition. December 1, 2022;27(24):1-3.
Healthcare Excellence Canada. 2022.
Meyer DB. Boca Raton, FL: Universal Publishers; 2022. ISBN: 9781627344067
Patient falls are a never event and a frequent focus of patient safety and quality improvement projects. This pediatric ICU implemented a colored alert system based on fall risk assessments for all admitted patients.
This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.
Raffel K, Ranji S. UpToDate. July 25, 2022.
West S. Kaiser Health News. August 5, 2022.