Major VTE risk factors • Malignancy • Personal history of previous VTE • Family history of VTE • Prolonged surgical procedure (>2 h) • Major general surgery • Major traumatic injury • Hip or leg fracture • Hip…
Safety Freedom from accidental injuries Error The failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve…
Fig. 39.1 RCA time line of event The second meeting to ascertain why the event occurred never happened as Kelly’s self-assignment of blame was accepted as the root cause. Table…
Fig. 36.1 Transitions across surgical care. Figure reprinted with permission from the American Society of Anesthesiologists (asahq.org/psh) Each transition of care, from one phase in the surgical pathway to another,…
Fig. 14.1 % Positive responses over time by MSWBI question (composite of all classes). Percentage (vertical axis) of positive (“yes”) responses to each MSWBI question for all students grouped by…
Fig. 26.1 Comprehensive Surgical Checklist. Reprinted with permission from AORN.org. Copyright © 2016, AORN, Inc.: Denver, CO. All rights reserved In particular, interventions to prevent or reduce never events include:…
• Correct patient, correct site operation • Avoiding harm related to anesthesia while controlling pain • Recognition and effective preparation for life-threatening loss of airway or respiratory function • Recognition…
Fig. 49.1 Location of Critical Access Hospitals. Permission to reprint confirmed from location of critical access hospitals. Flex Monitoring Team. http://www.flexmonitoring.org/wp-content/uploads/2013/06/CAH_031816.pdf. Updated 2016. Accessed 03/24, 2016 [9] The Rural Surgeon:…
Fig. 42.1 ISQIC conceptual model The Nuts and Bolts of a Quality Improvement Collaborative The common characteristics of QI Collaboratives have been well described [2, 10] and emphasize collaborative learning,…
Fig. 38.1 Opportunities for patient and family engagement after a harmful event Patients and families can be interviewed informally, be sent a written survey about the events they experienced, be…
