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[SURGICAL "NEVER EVENTS" IN THE ANTERIOR CERVICAL APPROACH].

Harefuah 2022 March
This article deals with incidents which involved damages that could have been prevented. This includes patients who have been suffocated and have suffered irreversible damage, unfortunately, as far as we know, due to the powerlessness of the medical staff who did not act suitably. The disasters have happened as a result of upper respiratory airway obstruction by a blood clot (retropharyngeal hematoma) that developed as a complication after an anterior cervical surgery (spine/carotid artery) or after a sharp cervical injury. The main question that derives from the following cases is whether it was possible to prevent the unnecessary death and/or the severe ongoing disability of the patients by choosing a different form of medical treatment. We are dealing with common practical knowledge, while referring to the importance of the immediate concern about the airway of patients after an anterior cervical surgery both by the nursing and the treating medical staff and also, by the risk managers. Malpractice events are very important educational material for the medical and nursing staff in order to avoid such preventable cases. Right before our eyes, a real revolution is happening in terms of digital medicine. This revolution may change the current comprehension among physicians about medical decisions, diagnosis and treatment selection. All of the above is being done by the rare resource that we possess which is the human resource. However, the problem is that in many medical cases, for instance the ones mentioned in the article, the medical treatment method for the patient will not benefit from digital medicine, moreso, in those cases we depend on the human resource. The purpose of this work is mainly to make an intellectual-behavioral change among medical staff, nurses and physicians, in terms of complaints such as dysphagia or respiratory difficulties after anterior cervical surgery. Time has a crucial role in those emergency cases, therefore complete seriousness, caution and a rapid airway opening are demanded in the described circumstances.

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