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- Surgical Complications 9
Search results for "Neurosurgery"
- Active Errors
Cases & Commentaries
- Web M&M
Yi Lu, MD, PhD, and Douglas Salvador, MD, MPH; August 2019
A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure. She was transferred to a neurosurgery service at an academic hospital when an MRI revealed a T6–T10 thoracic epidural abscess.
Biel L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Journal Article > Study
Howard BM, Holland CM, Mehta CC, et al. JAMA Surg. 2018;153:313-321.
Overlapping surgery refers to the practice of surgeons scheduling two procedures performed on different patients concurrently. This practice has raised safety concerns in light of news investigations, which prompted a government inquiry into concurrent surgery policies. This single-center retrospective study of 2275 neurosurgery cases at an academic medical center compared overlapping to nonoverlapping procedures. The majority of surgeries were overlapping, and rates of morbidity and mortality did not differ between overlapping and nonoverlapping cases. These findings suggest that overlapping surgery can be conducted safely.
Baker M. Seattle Times. February 10, 2017.
Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patient and family concerns. A past WebM&M commentary highlighted the importance of listening to families when they advocate for patients in the hospital.
Journal Article > Commentary
Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents.
Graudins LV, Downey G, Bui T, Dooley MJ. Jt Comm J Qual Patient Saf. 2016;42:86-95.
Administration errors involving high-alert medications have the potential to cause serious patient harm. This commentary discusses one hospital's effort to reduce errors associated with neuromuscular blocking agents. The authors used root cause analysis to identify weaknesses in labeling, storage, and packaging methods, and implemented guidelines to reduce risk of errors involving such medications.
Marsh H. New York, NY: Thomas Dunne Books; 2015. ISBN: 9781250065810.
This intensely personal memoir by the famed British neurosurgeon Henry Marsh is no hagiography or recitation of his many accomplishments. Instead, Marsh relates many errors he has committed or witnessed, and the personal toll these errors have taken on his patients and himself. He recreates these stories in vivid detail, acknowledging the effect that his own emotional state had on committing both cognitive and technical errors. Marsh was inspired to write this book in part by reading the work of Daniel Kahneman, the Nobel Prize–winning psychologist whose research established the mechanisms by which humans commit cognitive errors. Along with Atul Gawande's Complications, this book stands as an essential human perspective on error in medicine.
Hamblin J. The Atlantic. March 17, 2014.
Reporting on the use of checklists, this magazine article describes studies that identified benefits, such as reduced complication rates, along with research that questioned the effectiveness of checklists in improving safety. The article also discusses how these assessments may influence checklist application in health care over time.
Journal Article > Study
Oszvald Á, Vatter H, Byhahn C, Seifert V, Güresir E. Neurosurg Focus. 2012;33:E6.
Implementation of an advanced perioperative checklist, which included a requirement for a team time-out, improved patient safety in a German neurosurgery department.
Journal Article > Study
Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.
This study found that communication breakdowns, inadequate preoperative checks, technical factors, and human error were the primary categories identified in assessing the root causes of wrong-site craniotomy. The authors suggest that the events were preventable had proper compliance with protocols taken place.
Associated Press. MSNBC. November 27, 2007.
This news article reports repeated incidents of wrong-side surgery at the same facility, and state and hospital reactions to the errors.