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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
- Spotlight Case
- Web M&M
Ernest J. Ring, MD; Jane E. Hirsch, RN, MS; October 2009
Cardiology consultation on an elderly man admitted to the orthopedic service following a hip fracture reveals aortic stenosis. The cardiologist recommends against surgery, due to the risk of anesthesia. When the nurse reads these recommendations to the orthopedic resident, he calls her "stupid" and contacts the OR to schedule the surgery anyway. The Chief Medical Officer is called to intervene.
Perspectives on Safety > Perspective
with commentary by Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD, Outpatient Safety, May 2006
Over the last decade, surgical operations and interventional procedures have been performed increasingly in offices with the administration of office-based anesthesia (OBA).(1) Economic considerations and convenience have driven this increase. Schultz...
Journal Article > Study
Coldiron B, Fisher AH, Adelman E, et al. Dermatol Surg. 2005;31(pt 1):1079-1092; discussion 1093.
The investigators examined reported adverse incidents from office surgical procedures and found no correlation between facility accreditation or physician board certification and medical errors.
Brandeland GP. Med Econ. 2006 Oct 20;83:50, 52-53.
This author shares his experience as a young physician dealing with the aftermath of a medical error and how the incident affected his practice, his personal relationships, and the patient's family.
Saltzman W. ABC/WPVI. February 5, 2013.
Hartocollis A, Goodman JD. New York Times. September 9, 2014.
Office-based anesthesia is becoming more common despite concerns regarding its safety. This newspaper article reports on factors to enhance safety of surgical care in ambulatory settings, such as adequate screening of patient risks, availability of staff trained to perform intubations when needed, and ensuring access to lifesaving equipment as strategies.
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.