Patient Safety Vignettes

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Anatomy of a Near Miss

A middle-aged super-obese man was hospitalized repeatedly for respiratory failure due to obesity-hypoventilation and obstructive sleep apnea. Multiple other comorbidities...
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GI Bleed Post-RYGB Management Disaster, with Invited Discussion by Shanu Kothari, MD

A male in his late 30s with a high BMI was known to be hypertensive, with OSA for which he...
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The Risk of Post-RYGB ‘Plastic Surgery,’ with Invited Discussion by Barry Fisher,...

A woman in her 40s, years after successful open gastric bypass, had her bariatric surgeon perform concurrent ventral hernioplasty, panniculectomy...
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A Surgeon’s Nightmare: The Importance of the Consent Process in the Aftermath...

An older patient with symptoms of cholecystitis and an ultrasound completed within the past two years, after appropriate clearance, had...
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A Fatal Cascade: The Importance of ‘History,’ with Invited Discussion by Dan...

A woman who had undergone LRYGB and cholecystectomy had subsequently developed severe malnutrition and a ventral hernia, and five years...
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The Importance of Surgeon – Anesthesiologist Communication, With Invited Discussion by Eric...

A woman in her 20s underwent laparoscopic gastric bypass, with the procedure started at the time of anesthesia change over....
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Anastomotic Failure and Staple Length, with Invited Discussion by Kelvin Higa, MD

A male in his 60s, with a BMI of 48, underwent LRYGB with 2.5 mm staples used at the jejuno-jejunostomy...
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Risks of Non-Standard Surgery, with Invited Discussion by Jaime Ponce, MD

A truck driver in his 50s, without insurance coverage, underwent lap band surgery in Mexico, at a quarter of the...
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Lap Band Placement Gone Awry, and the Cascade That Followed, with Invited...

A woman in her 40s underwent lap band placement and had her stomach perforated in the attempt, confirmed by the...
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Disastrous Team Training and Handoff Management, With Invited Discussion by John Baker,...

A woman in her 50s underwent LYRGB with a 21 EEA circular stapler. A first day blue dye test per...