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Chapter 12: Patient Safety

The Donabedian model of measuring quality identifies all of the following as main types of improvements EXCEPT

A. Changes to structure

B. Changes to process

C. Changes to culture

D. Changes to outcomes

Answer: C

The Donabedian model of measuring quality identifies three main types of improvements: changes to structure, process, and outcome (Fig. 12-1). (See Schwartz 10th ed., p. 367.)

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Fig. 12-1. Donabedian model for measuring quality. (From Makary MA, Sexton JB, Freischlag JA, et al, Patient safety in surgery. Ann Surg 243:628, 2006. With Permission.)

The most common delayed complication following carotid endarterectomy is

A. Arteriovenous fistulae

B. Myocardial infarction

C. Expanding neck hematoma

D. Localized neurologic deficit

Answer: B

Complications of carotid endarterectomy include central or regional neurologic deficits or bleeding with an expanding neck hematoma. An acute change in mental status or the presence of localized neurologic deficit requires an immediate return to the operating room (OR). An expanding hematoma may warrant emergent airway intubation and subsequent transfer to the OR for control of hemorrhage. Intraoperative anticoagulation with heparin during carotid surgery makes bleeding a postoperative risk. Other complications include arteriovenous fistulae, pseudoaneurysms, and infection, all of which are treated surgically.

Intraoperative hypotension during manipulation of the carotid bifurcation can occur and is related to increased tone from baroreceptors that reflexly cause bradycardia. Should hypotension occur when manipulating the carotid bifurcation, an injection of 1% lidocaine solution around this structure should attenuate this reflexive response. The most common delayed complication following carotid endarterectomy remains myocardial infarction. The possibility of a postoperative myocardial infarction should be considered a cause of labile blood pressure and arrhythmias in high-risk patients. (See Schwartz 10th ed., p. 384.)

The most appropriate treatment for a seroma after a soft-tissue biopsy is

A. Multiple attempts of aspiration with application of pressure dressings.

B. Immediate return to the OR for drainage.

C. Single attempt at aspiration with return to the OR if it recurs.

D. Observation.

Answer: A

Lymph node biopsies have direct and indirect complications that include bleeding, infection, lymph leakage, and seromas. Measures to prevent direct complications include proper surgical hemostasis, ...

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