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241. The second victim of unanticipated adverse events. | PSNet
     psnet.ahrq.gov/issue/second-victim-unanticipated-adverse-events
     February 12, 2020 - Related Resources From the Same Author(s) Impact of staff turnover during cardiac … February 12, 2020 Mortality due to hospital-acquired infection after cardiac surgery. … 2023 Transparency, public reporting, and a culture of change to quality and safety in cardiac … Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac

242. Too Many Cooks Spotlight Pdf (pdf file)
     psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
     January 01, 2020 - alerts in postoperative care, and identify several factors that might trigger such alerts based on cardiac … risk after non-cardiac surgery 3 TOO MANY COOKS IN THE KITCHEN A case describing deviations in the … Aortic stenosis and non-cardiac surgery: A systematic review and meta-analysis. … Multifactorial index of cardiac risk in noncardiac surgical procedures. … Examining Risk: A Systematic Review of Perioperative Cardiac Risk Prediction Indices.

243. Impact of age on anaesthesiologists' competence: a narrative review. | PSNet
     psnet.ahrq.gov/issue/impact-age-anaesthesiologists-competence-narrative-review
     December 15, 2014 - April 19, 2023 Crisis scenarios for simulation-based nontechnical skills training for cardiac … surgery teams: a national survey among cardiac anesthesiologists, cardiac surgeons, clinical perfusionists … , and cardiac operating room nurses. … Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac

244. Epidemiology of adverse events and medical errors in the care of cardiology patients. | PSNet
     psnet.ahrq.gov/issue/epidemiology-adverse-events-and-medical-errors-care-cardiology-patients
     November 26, 2014 - Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac … Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac … November 1, 2016 Application of the aviation black box principle in pediatric cardiac … surgery: tracking all failures in the pediatric cardiac operating room. … April 13, 2011 Critical incidents related to cardiac arrests reported to the Danish Patient

245. Can the standard configuration of a cardiac monitor lead to medical errors under a stress induction? | PSNet
     psnet.ahrq.gov/issue/can-standard-configuration-cardiac-monitor-lead-medical-errors-under-stress-induction
     May 19, 2021 - Study Can the standard configuration of a cardiac monitor lead to medical errors … Can the standard configuration of a cardiac monitor lead to medical errors under a stress induction? … Can the standard configuration of a cardiac monitor lead to medical errors under a stress induction?

246. Haste Makes Care Unsafe | PSNet
     psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
     January 07, 2015 - At that point, the surgeon was informed that another patient in the cardiac intensive care unit (ICU) … The surgeon was the only cardiac surgeon available that day, and there was also only one cardiac anesthesia … Echocardiographic direct observation of cardiac valvular function, volume of blood in the heart, and … Take-Home Points Pulmonary artery catheters may still be used in cardiac surgery cases, but they … Strengthening handover communication in pediatric cardiac intensive care.

247. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865984/psn-pdf
     May 29, 2024 - wave changes, and the presence of Q waves could all indicate prior ischemic events and should raise cardiac … stress testing does not rely on functional capacity and is a more suitable method of assessing for cardiac … Patients with elevated HEART scores of 4 or greater have markedly increased of a major adverse cardiac … Clinical Presentations and Outcomes in Patients Presenting With Acute Cardiac Events and Right Bundle … Evidence-based algorithms using high-sensitivity cardiac troponin in the emergency department.

248. Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
     January 01, 2020 - Lytes Go Out_SLIDES_08.25.2020-revised.pptx Spotlight When the Lytes Go Out: A Case of Inpatient Cardiac … that can lead to complications or poor outcomes 3 WHEN THE LYTES GO OUT: A CASE OF INPATIENT CARDIAC … ARREST A case describing serious and preventable complications – cardiac arrest due to torsades de … interval 6 Case Details • On Day 7, potassium and magnesium remained low • The patient had a cardiac … arrest due to torsades de points and ventricular fibrillation • Patient was transported to the cardiac

249. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50697/psn-pdf
     November 27, 2019 - Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation November 27, 2019 Kulig CE, Ebong IA … Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet]. 2019. … https://psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation The Case A 36-year-old … She was resuscitated according to the advanced cardiac life support protocol and received intravenous … The error in this case was only recognized after the patient suffered a cardiac arrest.

250. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49824/psn-pdf
     March 01, 2018 - /missing-ecg-and-missed-diagnosis-lead-dangerous-delay The Case A 35-year-old woman with no prior cardiac … transmit the ECG to the emergency department (ED) to activate "Code STEMI" while en route so that the cardiac … She was rushed to the cardiac catheterization laboratory for emergency percutaneous coronary intervention … ultimately required placement of a device to assist her heart function and a prolonged stay in the cardiac … Code STEMI is designed to achieve timely activation of the cardiac catheterization laboratory.(4) The

251. Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance. | PSNet
     psnet.ahrq.gov/issue/standardized-postoperative-handover-process-improves-outcomes-intensive-care-unit-model
     June 21, 2015 - Transitions of care in the pediatric cardiac intensive care unit*. … standardized handoff tool was associated with a decrease in postoperative adverse events in pediatric cardiac … Transitions of care in the pediatric cardiac intensive care unit*.

252. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60952/psn-pdf
     September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac Arrest September 30, 2020 Stripe B, Zuidema D. … When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020. … https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest Disclosure of Relevant … a cardiac arrest due to?torsades?de pointes and ventricular fibrillation.? … He was transported to the cardiac intensive care with return of spontaneous circulation.

253. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients | PSNet
     psnet.ahrq.gov/web-mm/nonsustained-ventricular-tachycardia-after-acute-coronary-syndromes-recognizing-high-risk
     September 20, 2011 - About 2 hours after the initial run of VT, the patient experienced a cardiac arrest secondary to sustained … led the patient to a care environment that was more vigilant and better equipped for management of cardiac … Unfortunately, large studies have failed to show improved survival following in-hospital cardiac arrest … Kristin Newby, MD, MHS Professor of Medicine Co-Director, Cardiac Care Unit Duke University … Automated external defibrillators and survival after in-hospital cardiac arrest.

254. Premature Closure: Was It Just Syncope? | PSNet
     psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
     February 10, 2021 - Concerned for a cardiac etiology of syncope, the emergency physician administered aspirin, started the … patient on an unfractionated heparin drip, and ordered an echocardiogram to assess cardiac function. … This led to a framing error and premature closure around isolated cardiac pathology. … Additionally, had the clinician not closed on a cardiac diagnosis prematurely, they likely would have … ECG changes are not always ischemic and do not always indicate primary cardiac pathology.

255. Four years' experience with a hospitalist-led medical emergency team: an interrupted time series. | PSNet
     psnet.ahrq.gov/issue/four-years-experience-hospitalist-led-medical-emergency-team-interrupted-time-series
     October 03, 2011 - system consisting of a hospitalist, critical care nurse, and respiratory therapist successfully reduced cardiac … March 5, 2010 Changing cardiac arrest and hospital mortality rates through a medical … February 3, 2010 A reduction in cardiac arrests and duration of clinical instability

256. Epidemiology and patient outcome after medical emergency team calls triggered by atrial fibrillation. | PSNet
     psnet.ahrq.gov/issue/epidemiology-and-patient-outcome-after-medical-emergency-team-calls-triggered-atrial
     March 05, 2010 - Atrial fibrillation, a common cardiac arrhythmia, triggered a significant proportion of rapid response … May 25, 2010 Changing cardiac arrest and hospital mortality rates through a medical emergency … February 3, 2010 A reduction in cardiac arrests and duration of clinical instability

257. Associations of workflow disruptions in the operating room with surgical outcomes: a systematic review and narrative synthesis. | PSNet
     psnet.ahrq.gov/issue/associations-workflow-disruptions-operating-room-surgical-outcomes-systematic-review-and
     April 03, 2019 - Related Resources Crisis scenarios for simulation-based nontechnical skills training for cardiac … surgery teams: a national survey among cardiac anesthesiologists, cardiac surgeons, clinical perfusionists … , and cardiac operating room nurses.

258. Using clinical simulation to study how to improve quality and safety in healthcare. | PSNet
     psnet.ahrq.gov/issue/using-clinical-simulation-study-how-improve-quality-and-safety-healthcare
     March 31, 2021 - June 21, 2023 Crisis scenarios for simulation-based nontechnical skills training for cardiac … surgery teams: a national survey among cardiac anesthesiologists, cardiac surgeons, clinical perfusionists … , and cardiac operating room nurses.

259. Unexpected death within 72 hours of emergency department visit: were those deaths preventable? | PSNet
     psnet.ahrq.gov/issue/unexpected-death-within-72-hours-emergency-department-visit-were-those-deaths-preventable
     July 08, 2020 - Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac … September 8, 2021 Impact of staff turnover during cardiac surgical procedures. … September 7, 2016 Ambulance diversion associated with reduced access to cardiac technology … July 3, 2014 Critical incidents related to cardiac arrests reported to the Danish Patient

260. Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review. | PSNet
     psnet.ahrq.gov/issue/trauma-resuscitation-using-situ-simulation-team-training-trust-study-latent-safety-threat
     October 27, 2021 - Related Resources Crisis scenarios for simulation-based nontechnical skills training for cardiac … surgery teams: a national survey among cardiac anesthesiologists, cardiac surgeons, clinical perfusionists … , and cardiac operating room nurses.