Ugeskrift for laeger
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This paper illustrates how reporting of adverse events can be used to introduce changes in an organization. Starting from reports of incidents on wrong-site surgery, a method to prevent them and its implementation in the Copenhagen Hospital Corporation (H:S) are described. ⋯ Wrong-site surgery is a rare but serious adverse event. This paper describes the results of root cause analyses after reports of incidents in the H:S. The analyses showed a need for better and more structured communication and identification of patients before surgical intervention.
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Ugeskrift for laeger · Nov 2006
Review Comparative Study[Serrated, hyperplastic and hyperplasia-like colorectal polyps].
The colorectal hyperplastic polyp has generally been considered a finding of no clinical significance. Recent research has, however, called attention to the existence of some variants of hyperplastic polyp which are potentially malignant. The term "advanced serrated polyp" has been coined for such cases, which comprise mixed hyperplastic/adenomatous tissue, serrated adenoma, and sessile serrated polyp, in contrast to the traditional hyperplastic polyp. ⋯ For this reason, a consensus regarding the optimal management of such patients has not been obtained, but if the polyp is sizeable and located in the right colon, control should be considered. The small, usually left-sided traditional polyp as a rule needs no follow-up, but the context in which such a lesion is found and its morphology may influence the clinical decision. Future large-scale investigations of serrated colorectal polyps, including interobserver studies, will be required to identify histological details of clinical utility which can be adopted in daily routine practice.
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Fatal pulmonary thromboembolism is a relatively common autopsy finding. The aim of this investigation is to describe the magnitude of the problem in an autopsy material and factors of prophylactic importance and to discuss the importance of the autopsy. ⋯ The diagnosis is sometimes not made before the autopsy. The decreasing autopsy frequency may result in a lack of diagnosis of pulmonary embolism as cause of death.