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241. 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

242. When my father died. | PSNet
     psnet.ahrq.gov/issue/when-my-father-died
     July 01, 2011 - Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac … June 8, 2022 WebM&M Cases Management of Cardiac Arrest … April 5, 2017 In situ simulated cardiac arrest exercises to detect system vulnerabilities … June 10, 2015 A patient safety checklist for the cardiac catheterisation laboratory. … March 17, 2015 A team-based approach to reducing cardiac monitor alarms.

243. 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*.

244. 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

245. Management of anesthesia equipment failure: a simulation-based resident skill assessment. | PSNet
     psnet.ahrq.gov/issue/management-anesthesia-equipment-failure-simulation-based-resident-skill-assessment
     December 20, 2017 - 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. … Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac

246. A conceptual framework to reduce inpatient preventable deaths. | PSNet
     psnet.ahrq.gov/issue/conceptual-framework-reduce-inpatient-preventable-deaths
     April 24, 2018 - Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac … June 8, 2022 WebM&M Cases Management of Cardiac Arrest … April 5, 2017 In situ simulated cardiac arrest exercises to detect system vulnerabilities … June 10, 2015 A patient safety checklist for the cardiac catheterisation laboratory. … March 17, 2015 A team-based approach to reducing cardiac monitor alarms.

247. 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.

248. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest | PSNet
     psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
     April 01, 2008 - Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac … Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac … Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac … Before the child could be transfused, she suddenly collapsed and developed cardiac arrest accompanied … Prospective analysis of percutaneous central venous catheterization in infants <4.0 kg undergoing cardiac

249. 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

250. 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

251. 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

252. On O.R. Off? | PSNet
     psnet.ahrq.gov/web-mm/or
     August 22, 2013 - The patient remained "NPO" overnight in anticipation of the cardiac catheterization. … They assumed he was undergoing cardiac catheterization. … Cardiac catheterization and peripheral arterial bypass surgery were later completed successfully. … The patient was determined to be at significant cardiac risk, precluding surgery and requiring further … Cardiologists are frequently asked to evaluate cardiac risk for patients undergoing peripheral vascular

253. 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

254. 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

255. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39990/psn-pdf
     June 08, 2011 - crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac … crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac … wolf-crying-operating-room-patient-monitor-and-anesthesia-workstation- alarming-patterns Anesthesia equipment alarms went off approximately once per minute during cardiac

256. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40470/psn-pdf
     December 21, 2014 - Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac … Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac … prospective-evaluation-consultant-surgeon-sleep-deprivation-and-outcomes- more-4000 This prospective study found no additional risk of complications or mortality in cardiac

257. 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

258. 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.

259. 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.

260. 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.