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141. MGH halts a pediatric program: Heart surgeries on hold after errors. | PSNet
     psnet.ahrq.gov/issue/mgh-halts-pediatric-program-heart-surgeries-hold-after-errors
     August 24, 2016 - This newspaper article discusses one hospital's decision to temporarily close its pediatric cardiac surgery … March 24, 2016 Application of the aviation black box principle in pediatric cardiac surgery … : tracking all failures in the pediatric cardiac operating room. … July 31, 2012 A prospective study of paediatric cardiac surgical microsystems: assessing

142. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43709/psn-pdf
     December 04, 2014 - A team-based approach to reducing cardiac monitor alarms. … A team-based approach to reducing cardiac monitor alarms. … https://psnet.ahrq.gov/issue/team-based-approach-reducing-cardiac-monitor-alarms Improving alarm systems … The program included standardized steps for ordering and reassessing cardiac monitor parameters. … In addition, physicians and nurses used a log to document the need for ongoing cardiac monitoring and

143. Communication Failure—Who's in Charge? | PSNet
     psnet.ahrq.gov/web-mm/communication-failure-whos-charge
     April 01, 2018 - The child suffered a cardiac arrest at 7:00 AM from low cardiac output. … similarly, the ICU attending focused on stabilizing the child's respiratory status and missed his low cardiac … teams focused on children with cardiac problems. … May 25, 2011 A reduction in cardiac arrests and duration of clinical instability after … December 16, 2009 Nurses' perceptions of subspecialization in pediatric cardiac intensive

144. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37926/psn-pdf
     July 30, 2008 - Adaptive coordination in cardiac anaesthesia: a study of situational changes in coordination patterns … Adaptive coordination in cardiac anaesthesia: a study of situational changes in coordination patterns … https://psnet.ahrq.gov/issue/adaptive-coordination-cardiac-anaesthesia-study-situational-changes- coordination-patterns … This study used direct observation to evaluate how anesthesia teams engaged in teamwork during cardiac … https://psnet.ahrq.gov/issue/adaptive-coordination-cardiac-anaesthesia-study-situational-changes-coordination-patterns

145. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40174/psn-pdf
     December 21, 2014 - Physician implicit review to identify preventable errors during in-hospital cardiac arrest. … Physician implicit review to identify preventable errors during in-hospital cardiac arrest. … https://psnet.ahrq.gov/issue/physician-implicit-review-identify-preventable-errors-during-hospital-cardiac … - arrest This research letter discusses a review of cardiac arrest cases that found 25% of these cases … https://psnet.ahrq.gov/issue/physician-implicit-review-identify-preventable-errors-during-hospital-cardiac-arrest

146. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865429/psn-pdf
     April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery April 24, 2024 Bohringer … Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. 2024. … https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery Disclosure … He underwent cardiac catheterization, which showed 3-vessel coronary artery disease and severe aortic … Pacing induced recurrent ventricular fibrillation following cardiac surgery.

147. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837065/psn-pdf
     May 11, 2022 - Fast tracking in cardiac surgery: is it safe? … Fast tracking in cardiac surgery: is it safe? … https://psnet.ahrq.gov/issue/fast-tracking-cardiac-surgery-it-safe Post-operative complications can … https://psnet.ahrq.gov/issue/fast-tracking-cardiac-surgery-it-safe https://psnet.ahrq.gov/issue/comprehensive-estimation-costs

148. A systems approach to analyzing and preventing hospital adverse events. | PSNet
     psnet.ahrq.gov/issue/systems-approach-analyzing-and-preventing-hospital-adverse-events
     March 30, 2022 - January 23, 2017 Safety culture in cardiac surgical teams: data from five programs and … January 22, 2016 Application of the aviation black box principle in pediatric cardiac … surgery: tracking all failures in the pediatric cardiac operating room. … February 25, 2015 Cardiac surgical ICU care: eliminating "preventable" complications. … September 11, 2013 Quality, patient safety, and the cardiac surgical team.

149. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33956/psn-pdf
     March 07, 2005 - The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry into Twelve Deaths at the Winnipeg … March 7, 2005 Inquest, Manitoba Pediatric Cardiac Surgery. … https://psnet.ahrq.gov/issue/report-manitoba-pediatric-cardiac-surgery-inquest-inquiry-twelve-deaths- … winnipeg-health A 3-year review investigating a series of deaths from a pediatric cardiac unit revealed … https://psnet.ahrq.gov/issue/report-manitoba-pediatric-cardiac-surgery-inquest-inquiry-twelve-deaths-winnipeg-health

150. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38541/psn-pdf
     May 21, 2009 - The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level … The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level … https://psnet.ahrq.gov/issue/relationship-between-inpatient-cardiac-surgery-mortality-and-nurse-numbers … postoperative general wards—but not in the intensive care unit—was associated with reduced mortality for cardiac … https://psnet.ahrq.gov/issue/relationship-between-inpatient-cardiac-surgery-mortality-and-nurse-numbers-and-educational

151. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39240/psn-pdf
     January 20, 2010 - Importance of prevention and early intervention of adverse events in pediatric cardiac catheterization … Importance of prevention and early intervention of adverse events in pediatric cardiac catheterization … https://psnet.ahrq.gov/issue/importance-prevention-and-early-intervention-adverse-events-pediatric- cardiac-catheterization … This study sought to quantify the incidence and types of adverse events associated with pediatric cardiac … https://psnet.ahrq.gov/issue/importance-prevention-and-early-intervention-adverse-events-pediatric-cardiac-catheterization

152. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36906/psn-pdf
     September 01, 2011 - Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit. … Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit. … https://psnet.ahrq.gov/issue/implementation-rapid-response-team-decreases-cardiac-arrest-outside- intensive-care-unit … data on the use of a rapid response team (RRT) in their hospital and found a 50% reduction in non-ICU cardiac … https://psnet.ahrq.gov/issue/implementation-rapid-response-team-decreases-cardiac-arrest-outside-intensive-care-unit

153. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40490/psn-pdf
     June 01, 2011 - Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive … Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive … https://psnet.ahrq.gov/issue/standardized-multidisciplinary-protocol-improves-handover-cardiac-surgery … formal handoff system reduced technical errors and improved the quality of handoffs when transferring cardiac … https://psnet.ahrq.gov/issue/standardized-multidisciplinary-protocol-improves-handover-cardiac-surgery-patients-intensive

154. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46677/psn-pdf
     June 25, 2018 - Diagnostic errors in paediatric cardiac intensive care. … Diagnostic errors in paediatric cardiac intensive care. … https://psnet.ahrq.gov/issue/diagnostic-errors-paediatric-cardiac-intensive-care Researchers surveyed … pediatric cardiac intensive care unit providers across three tertiary cardiac centers in the United … https://psnet.ahrq.gov/issue/diagnostic-errors-paediatric-cardiac-intensive-care https://psnet.ahrq.gov

155. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42047/psn-pdf
     March 18, 2013 - Checklists and cardiac exam. March 18, 2013 Sibbald M, de Bruin A, Cavalcanti RB, et al. … Checklists and cardiac exam. BMJ Qual Saf. 2013;22(4):333-8. doi:10.1136/bmjqs-2012-001537. … https://psnet.ahrq.gov/issue/do-you-have-re-examine-reconsider-your-diagnosis-checklists-and-cardiac- … In this study, internal medicine residents examined a high-fidelity cardiac simulator and then were … given a checklist that outlined the major aspects of the cardiac exam.

156. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37415/psn-pdf
     March 03, 2011 - Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan … Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan … https://psnet.ahrq.gov/issue/six-year-audit-cardiac-arrests-and-medical-emergency-team-calls-australian … hospital with a long-standing medical emergency team has had a significant and sustained decline in cardiac … https://psnet.ahrq.gov/issue/six-year-audit-cardiac-arrests-and-medical-emergency-team-calls-australian-outer-metropolitan

157. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43753/psn-pdf
     December 10, 2014 - Improving the quality and safety of patient care in cardiac anesthesia. … Improving the quality and safety of patient care in cardiac anesthesia. … https://psnet.ahrq.gov/issue/improving-quality-and-safety-patient-care-cardiac-anesthesia This review … explores safety in cardiac surgery and suggests that the anesthesiologist in the surgical team is in … https://psnet.ahrq.gov/issue/improving-quality-and-safety-patient-care-cardiac-anesthesia https://psnet.ahrq.gov

158. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42413/psn-pdf
     July 31, 2013 - A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements … A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements … https://psnet.ahrq.gov/issue/handoff-protocol-cardiovascular-operating-room-cardiac-icu-associated- … improvements-care A standardized handoff protocol for cardiac surgery patients between the operating … https://psnet.ahrq.gov/issue/handoff-protocol-cardiovascular-operating-room-cardiac-icu-associated-improvements-care

159. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37183/psn-pdf
     October 06, 2011 - Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT attenuation and emission PET … Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT attenuation and emission PET … https://psnet.ahrq.gov/issue/frequent-diagnostic-errors-cardiac-petct-due-misregistration-ct-attenuation … - and-emission-pet In this study, 40% of cardiac PET/CT scans showed a false-positive result due to … https://psnet.ahrq.gov/issue/frequent-diagnostic-errors-cardiac-petct-due-misregistration-ct-attenuation-and-emission-pet

160. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47222/psn-pdf
     October 03, 2018 - Decision support tools, systems, and artificial intelligence in cardiac imaging. … Decision Support Tools, Systems, and Artificial Intelligence in Cardiac Imaging. … https://psnet.ahrq.gov/issue/decision-support-tools-systems-and-artificial-intelligence-cardiac-imaging … artificial intelligence can be utilized to inform diagnostic decision making and improve the accuracy of cardiac … https://psnet.ahrq.gov/issue/decision-support-tools-systems-and-artificial-intelligence-cardiac-imaging