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- Communication Improvement(50)
- Computerized Decision Support(4)
- Computerized Provider Order Entry (CPOE)(4)
- Culture of Safety(16)
- Education and Training(29)
- Error Reporting and Analysis(66)
- Human Factors Engineering(34)
- Legal and Policy Approaches(19)
- Logistical Approaches(9)
- Policies and Operations(9)
- Quality Improvement Strategies(63)
- Research Directions(7)
- Specialization of Care(4)
- Technologic Approaches(14)
- Device-Related Complications(19)
- Diagnostic Errors(7)
- Discontinuities, Gaps, and Hand-Off Problems(27)
- Failure to rescue(7)
- Fatigue and Sleep Deprivation(1)
- Identification Errors(3)
- Interruptions and distractions(1)
- Medical Complications(52)
- Medication Safety(29)
- Nonsurgical Procedural Complications(2)
- Psychological and Social Complications(6)
- Surgical Complications(217)
- Transfusion Complications(4)
- Transitions of Care(1)
This patient with recently diagnosed adenocarcinoma of the esophagus underwent esophagoscopy with endoscopic ultrasound, which was complicated by thoracic esophageal perforation. The perforation was endoscopically closed during the procedure. However, there was a lack of clear communication regarding the operator’s confidence in the success of endoscopic closure and their recommendations for the modality and timing of follow-up imaging, which ultimately led to significant delays in patient care.
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.
A 62-year-old Spanish-speaking woman presented to the pre-anesthesia area for elective removal of a left thigh lipoma. Expecting a relatively simple outpatient operation, the anesthesiologist opted not to use a Spanish language translator and performed a quick pre-anesthesia evaluation, obtaining her history from the medical record. Unknown to the anesthesiologist, the patient was trying to communicate to him that she had undergone jaw replacement surgery and that her mouth opening was therefore anatomically limited.
A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns.
A 49-year-old woman presented to an Emergency Department (ED) with abdominal pain nine hours after discharge following outpatient laparoscopic left oophorectomy. The left oophorectomy procedure involved an umbilical port placed using an Optiport visual trocar, a suprapubic port, and two additional ports laterally.
Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.