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- Communication Improvement 1
- Culture of Safety 2
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Legal and Policy Approaches 2
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Teamwork 1
- Technologic Approaches 1
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Interruptions and distractions 1
- Medical Complications 3
- Medication Safety 1
- Surgical Complications
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Cases & Commentaries
- Web M&M
Arpana Vidyarthi, MD; March 2004
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.
Cases & Commentaries
- Web M&M
Stephanie Rogers, MD, and Derek Ward, MD; April 2019
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath. He was found to have a pulmonary embolism; anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status.
Journal Article > Commentary
Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society.
Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. J Am Coll Surg. 2012;215:453-466.
This guideline describes recommendations for preoperative assessment of elderly surgical patients, including risk factors for postoperative delirium and pulmonary complications, to enhance safety and reduce readmissions.
Journal Article > Study
Nicholas LH, Osborne NH, Birkmeyer JD, Dimick JB. Arch Surg. 2010;145:999-1004.
Hospitals are now required to report adherence to measures intended to prevent post-surgical complications, including surgical site infections. These measures are being publicly reported by groups including the Centers for Medicare and Medicaid Services. However, this analysis found that high levels of adherence to these accountability measures were not correlated with postoperative mortality, surgical site infection rate, or other complications, calling into question the value of public reporting of such measures.
Journal Article > Review
The preventable proportion of healthcare-associated infections 2005–2016: systematic review and meta-analysis.
Schreiber PW, Sax H, Wolfensberger A, Clack L, Kuster SP; Swissnoso. Infect Control Hosp Epidemiol. 2018;39:1277-1295.
Health care–associated infections (HAIs) represent a significant source of preventable harm to patients. Targeted interventions have been shown to be effective in decreasing HAIs and events once deemed unavoidable, such as central line–associated bloodstream infections, are now considered preventable. In this systematic review and meta-analysis, investigators sought to determine the proportion of HAIs prevented by infection control efforts across countries of different income levels. From the 144 studies ultimately included in the analysis, they found that implementation of evidence-based interventions was associated with an overall reduction in HAIs and that there was no relationship to the financial status of the country in which the study was conducted. A past PSNet perspective discussed infection prevention and patient safety.