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- Communication Improvement 6
- Culture of Safety 1
- Legal and Policy Approaches 2
- Quality Improvement Strategies 2
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 1
Search results for "Outpatient Surgery"
- Discontinuities, Gaps, and Hand-Off Problems
- Outpatient Surgery
Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44.
This article details how miscommunication and lack of patient-centered care contributed to errors that led to the death of a child.
Ellis K. Surgicenteronline.com [serial online]. May 1, 2006.
This article discusses the application of several Joint Commission on Accreditation of Healthcare Organizations (JCAHO) National Patient Safety Goals in ambulatory surgery centers (ASCs) and interviews one practitioner about implementing patient safety interventions in his ASC.
Cases & Commentaries
- Web M&M
Jeanna Blitz, MD; November 2018
When patients in two cases did not receive complete preanesthetic evaluation, problems with intubation ensued. In the first case, an anesthesiologist went to evaluate a morbidly obese patient scheduled for hysteroscopy. As the patient was donning her hospital gown behind a closed curtain, he waited but left without performing the preoperative assessment because the morning surgery list was overbooked and he had many other patients to see. Once in the operating room, he discovered on chart review that the woman had a history of gastroesophageal reflux. She could not be intubated, and a supraglottic airway was placed. In the second case, an elderly man with a tumor mass at the base of his tongue was scheduled for a biopsy. On examination, the anesthesiologist could not see much of the mass with the patient's mouth maximally open and tongue sticking out, and he couldn't locate the patient's head and neck CT to further evaluate the mass. The surgeon arrived late and did not communicate with the anesthesiologist about the patient. After inducing general anesthesia, laryngoscopy and intubation proved extremely difficult as the mass obscured the view of the larynx. A second anesthesiologist was called, and together they were able to intubate the patient with a fiberoptic bronchoscope.
Cases & Commentaries
- Web M&M
Matt M. Kurrek, MD, and Rebecca S. Twersky, MD, MPH; August 2012
Following spinal anesthesia for an outpatient procedure, a patient is discharged and instructed to take sitz baths with tepid water. The patient misunderstood the instructions, using scalding water instead, and residual anesthesia blunted his response to the hot water.
Journal Article > Commentary
Gandhi TK, Lee TH. N Engl J Med. 2010;363:1001-1003.
This commentary discusses challenges for patient safety improvement work in the ambulatory setting along with recommendations for addressing them.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 25, 2007. Publication No. NOT-HS-08-002.
Journal Article > Study
Care transitions in the outpatient surgery preoperative process: facilitators and obstacles to information flow and their consequences.
Schultz K, Carayon P, Hundt AS, Springman SR. Cogn Technol Work. 2007;9:219-231.
Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.
Rockville, MD: United States Pharmacopeia; 2007.
This report shares findings from analysis of more than 11,000 perioperative medication errors reported through Medmarx and includes recommendations to avoid these types of errors.