منابع مشابه
Wrong-side thoracentesis: lessons learned from root cause analysis.
IMPORTANCE Despite the recognized value of the Joint Commission's Universal Protocol and the implementation of time-outs, incorrect surgical procedures are still among the most common types of sentinel events and can have fatal consequences. OBJECTIVES To examine a root cause analysis database for reported wrong-side thoracenteses and to determine the contributing factors associated with thei...
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A 59-year-old man with alcoholic liver disease became comatose from a left acute subdural hematoma. He developed a fixed dilated right pupil but the left pupil was responsive to light. Oculovestibular responses were normal. He had right extensor posturing. At autopsy uncal herniation was not found, but there was a diagonally shifted and rotated brainstem likely tethering or compressing the cont...
متن کاملWrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: Are they preventable?
HYPOTHESIS Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) are devastating, unacceptable, and often result in litigation, but their frequency and root causes are unknown. Wrong-side/wrong-site, wrong-procedure, and wrong-patient events are likely more common than realized, with little evidence that current prevention practice is adequate. DESIGN Analysis of se...
متن کاملWrong-side surgery: systems for prevention.
' 2003 Canadian Medical Association W surgery is probably the most dramatic, visible and devastating of all surgical errors. It is arguably the error most feared by surgeons. Recently, there was a prominently profiled neurosurgical case that received a lot of publicity, perhaps more than it might have because it occurred in a highly renowned medical institution in the United States. In this pap...
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When we use machine learning for public policy, we find that many useful variables are associated with others on which it would be ethically problematic to base decisions. This problem becomes particularly acute in the Big Data era, when predictions are often made in the absence of strong theories for underlying causal mechanisms. We describe the dangers to democratic decision-making when high-...
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ژورنال
عنوان ژورنال: JAMA Surgery
سال: 2014
ISSN: 2168-6254
DOI: 10.1001/jamasurg.2014.146