Medical Archive

Background

The Science of Patient Safety

High Reliability Organizations

The Institute Of Medicine Report

The Conceptual Model

Creating a Culture of Safety

Assessing An Organization’s Safety Culture

Teamwork and Communication

Measuring Teamwork

Communication Tools

Operating Room Briefings

Operating Room Debriefings

Sign Outs

Implementation

Comprehensive Unit-Based Safety Program

Measuring Quality in Surgery

Agency For Healthcare Research and Quality Patient Safety Indicators

The Surgical Care Improvement Project Measures

National Surgical Quality Improvement Program

The Leapfrog Group

World Health Organization “Safe Surgery Saves Lives” Initiative

National Quality Forum

“Never Events” in Surgery

Retained Surgical Items

Surgical Counts

Wrong-Site Surgery

The Joint Commission Universal Protocol To Ensure Correct Surgery

Transparency in Healthcare Risk Management

The Importance Of Communication in Managing Risk

Complications

Complications in Minor Procedures

Central venous access catheters

• Pneumothorax
  • From subclavian (1%), internal jugular vein (6%)
  • Unilateral absent breath sounds
• Arrhythmias
• Arterial puncture
• Lost guidewire
• Venous air embolus (VAE; 0.2%-1%)
  • Following removal of a CVC
  • Small VAE can diffuse into the alveoli without consequences
  • Large VAE (eg, >50mL) can lodge in the right ventricle to cause RVOTO.
    • Sudden-onset dyspnea with respriatory distress
    • Often accompanied by obstructive shock that can lead to cardiac arrest (eg, PEA)
  • Management
    • Left lateral decubitus positioning
    • High-flow or. hyperbaric oxygen
• Pulmonary artery rupture
• Central venous line infection

Arterial lines

Endoscopy and bronchoscopy

Tracheostomy

Percutaneous endogastrostomy

Tube thoracostomy

Organ System Complications

Wounds, Drains, And Infection

Nutritional And Metabolic Support Complications

Problems With Thermoregulation