AHRQ July/August WebM&M Available

July 1, 2013    |   By: Calevir

The most recent edition of AHRQ’s Morbidity & Morality spotlight cases are now available.   This edition includes cases covering Emergency Error, Discharge Instructions in the PACU – Who Remembers, and Anesthesia: A Weighty Issue…


An incorrectly diagnosed patient condition that led to an emergency surgery, resulting in the patient’s death…

AHRQ’s Take-Aways:

  • Emergency surgery is common and carries significantly higher risk than elective surgery.
  • Emergency laparotomy is particularly high risk and carries a 30-day mortality of about 15%; mortality is significantly higher in elderly patients.
  • Diagnosis and decision making for these patients can be challenging. Senior physicians are likely to be able to do this more reliably than those with less experience.
  • Basic processes of care for these patients are frequently incomplete or omitted. Utilization of simple interventions such as checklists, formal job descriptions, and Plan-Do-Study-Act cycles can improve the reliability of care.


A patient given verbal follow-up orders from her doctor while recovering in PACU, still groggy from anesthesia, was unable to recall the details and followed the non-specific written orders, resulting in an adverse outcome…

AHRQ’s Take-Aways:

  • Effective communication between providers, patients, families, and caregivers is a critically important aspect of patient care, which has significant implications for patient outcomes at times of transitions in care.
  • Communication with patients should be at or below a 6th grade reading level and the complexity and quantity of information should be limited.
  • Repetition and reinforcement of key information can provide patients the opportunity to receive and retain their instructions.
  • Opportunities to review (e.g., a teach-back), follow-up contact with a patient after discharge, and enhanced coordination of care with other providers may improve patient outcomes at times of transitions in care.
  • Providers should be sensitive to factors (related to the environment, patient, or themselves) that may make it difficult for a patient or family member to receive new information and consider approaches or interventions to minimize these challenges.


The health risks of an obese patient under anesthesia, highlighting the potential need for obese patients to receive formal preoperative screenings for obstructive sleep apnea…

AHRQ’s Take-Aways:

  • While providing anesthesia for obese and overweight patients, whenever possible consider multimodal analgesia and minimize the use of narcotics.
  • Patients with a diagnosis of OSA should be monitored carefully prior to considering discharge to home.
  • Keep a high index of suspicion for inappropriate ventilation in the post-operative period; obese patients have a low functional residual capacity along with a high metabolic demand for oxygen.
  • For short, supine procedures, spontaneous ventilation intraoperatively may be considered in patients who have no other contraindication like reflux.

View the AHRQ WebM&M and review the cases in their entirety.


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