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psnet.ahrq.gov/issue/intraoperative-deaths-who-why-and-can-we-prevent-them
November 04, 2020 - non-trauma-related emergency surgery, and patients who die during an elective procedure from medical cardiac … Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac
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psnet.ahrq.gov/issue/rapid-response-teams-patient-safety-practice-failure-rescue
January 26, 2022 - are intended to quickly identify clinical deterioration and prevent intensive care unit transfer, cardiac … does support that RRTs are associated with reduced secondary outcomes, such as ICU transfer rate and cardiac
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psnet.ahrq.gov/issue/mortality-and-risk-factors-associated-misdiagnosis-acute-aortic-syndrome-ontario-canada
September 23, 2020 - Presentation to a non-teaching hospital or non-cardiac emergency department increased the odds of misdiagnosis … April 8, 2018
Missed diagnoses of acute cardiac ischemia in the emergency department.
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psnet.ahrq.gov/node/41405/psn-pdf
December 30, 2014 - identifying-and-categorising-patient-safety-hazards-cardiovascular-operating-
rooms-using
Failure to address both operational and cultural factors in cardiac … This study used detailed
observation of cardiac surgical procedures by a multidisciplinary team, including
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psnet.ahrq.gov/node/40122/psn-pdf
February 01, 2011 - attitudes-and-barriers-medical-emergency-team-system-tertiary-paediatric-
hospital
Rapid response systems (RRS) have been shown to reduce cardiac … attitudes-and-barriers-medical-emergency-team-system-tertiary-paediatric-hospital
https://psnet.ahrq.gov/primer/rapid-response-systems
https://psnet.ahrq.gov/issue/reduction-cardiac-arrests-and-duration-clinical-instability-after-implementation-paediatric
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psnet.ahrq.gov/issue/impact-educational-initiative-targeting-non-radiologist-staff-overall-notification-times
March 09, 2022 - January 14, 2015
Safety culture in cardiac surgical teams: data from five programs and … February 9, 2011
Computerized physician order entry in the cardiac intensive care unit … March 27, 2013
Patient safety in the cardiac operating room: human factors and teamwork … February 14, 2024
Race and socioeconomic bias in pediatric cardiac transplantation. … , 2020
How strong is the evidence for the use of perioperative beta blockers in non-cardiac
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psnet.ahrq.gov/node/41176/psn-pdf
March 02, 2012 - between weekend care and overall complications, delays in
urgent procedures, survival from in-hospital cardiac … waiting-urgent-procedures-weekend-among-emergently-hospitalized-patients
https://psnet.ahrq.gov/issue/survival-hospital-cardiac-arrest-during-nights-and-weekends
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psnet.ahrq.gov/issue/management-operating-room-critical-events
March 27, 2024 - WebM&M Cases
Missed Connection: A Case of Inadequate ECG Oversight in Cardiac … WebM&M Cases
Uterine Artery Injury during Cesarean Delivery Leads to Cardiac
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psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - and Postpartum People with Substance Use Disorder (AIM)
Perinatal Mental Health Conditions (AIM)
Cardiac … These include maternal hemorrhage, preeclampsia, sepsis, and cardiac dysfunction. … Cardiac dysfunction is a complication referring to disorders of the cardiovascular system which may impact … The AIM Cardiac
Conditions in Obstetrical Care toolkit focuses on screening for basic cardiac conditions … High-risk cardiac disease in pregnancy: Part I. J Am Coll
Cardiol. 2016;68(4):396-410.
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psnet.ahrq.gov/issue/toward-improving-patient-safety-through-voluntary-peer-peer-assessment
August 25, 2015 - approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac … August 25, 2015
Cardiac surgery errors: results from the UK National Reporting and Learning … January 22, 2017
Safety culture in cardiac surgical teams: data from five programs and
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psnet.ahrq.gov/issue/finding-and-fixing-mistakes-do-checklists-work-clinicians-different-levels-experience
February 06, 2014 - Checklists and cardiac exam. … July 3, 2016
A patient safety checklist for the cardiac catheterisation laboratory. … Checklists and cardiac exam.
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psnet.ahrq.gov/issue/harm-susceptibility-model-method-prioritise-risks-identified-patient-safety-reporting-systems
December 29, 2014 - RIS
Download Citation
Related Resources From the Same Author(s)
Cardiac … May 1, 2015
Application of the aviation black box principle in pediatric cardiac surgery … : tracking all failures in the pediatric cardiac operating room.
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac … in maternal morbidity and mortality.
3
UTERINE ARTERY INJURY DURING
CESAREAN DELIVERY LEADS TO CARDIAC … • With laboratory tests and computed tomography (CT) pending, the patient
went into cardiac arrest … • In this case, the patient’s blood loss was so rapid that she went into cardiac arrest
while awaiting … CT, and this cardiac arrest triggered her resuscitation and
emergency laparotomy.
11
Overview
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psnet.ahrq.gov/node/39282/psn-pdf
September 20, 2011 - only overall complications but also delays in undergoing urgent procedures, survival from in-hospital
cardiac … waiting-urgent-procedures-weekend-among-emergently-hospitalized-patients
https://psnet.ahrq.gov/issue/survival-hospital-cardiac-arrest-during-nights-and-weekends
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psnet.ahrq.gov/node/39551/psn-pdf
May 26, 2010 - Simulation-based training improves physicians'
performance in patient care in high-stakes clinical setting
of cardiac … Simulation-based training improves physicians' performance
in patient care in high-stakes clinical setting of cardiac
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psnet.ahrq.gov/issue/overdiagnosis-coronary-artery-disease-detected-coronary-computed-tomography-angiography
March 03, 2011 - discusses how a communication gap left a patient uninformed about the risks associated with an invasive cardiac … May 29, 2024
WebM&M Cases
Management of Cardiac Arrest
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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - While being evaluated by the emergency physician, he suddenly went into cardiac arrest. … He was successfully resuscitated and underwent emergent cardiac catheterization, which revealed multivessel … radiographic findings and the date of the procedure should have been properly communicated from the cardiac … Third, the cardiac care team may have been inappropriately reassured that free air on the radiograph … January 31, 2011
Residents feel unprepared and unsupervised as leaders of cardiac arrest
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psnet.ahrq.gov/issue/wrong-patient
December 23, 2008 - This case study describes the events of a patient who underwent an unintended invasive cardiac electrophysiology … Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac
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psnet.ahrq.gov/issue/rescue-me-saving-vulnerable-non-icu-patient-population
June 01, 2011 - A nurse-led rapid response team achieved significant reductions in cardiac arrests and unanticipated … May 25, 2010
A reduction in cardiac arrests and duration of clinical instability after
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psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
January 01, 2024 - Autopsy confirmed sudden cardiac arrest without myocardial infarction as the cause of death.
7
7 … Unfortunately, the patient deteriorated and suffered sudden cardiac death likely due to TdP (meaning … In cardiac myocytes, the high selective permeability of potassium ion channels in the cell membrane generates … a negative resting membrane potential that stabilizes cardiac myocytes.5
Therefore, serum potassium … Finally, when resuscitating patients in cardiac arrest, responders should be mindful of the side effects