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421. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37539/psn-pdf
     June 16, 2019 - monthly selection of medication error reports provides examples of intravenous amphotericin mix-ups, cardiac

422. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-432
     March 27, 2024 - associated with longer wait times, longer time to medications and treatment, and increased risk of cardiac … associated with longer wait times, longer time to medications and treatment, and increased risk of cardiac … The patient progressed to cardiac arrest and chest tubes were placed on both sides of the chest. … WebM&M Cases Spotlight Case Uterine Artery Injury during Cesarean Delivery Leads to Cardiac … Following the delivery, the patient was noted to be hypotensive and tachycardic and went into cardiac

423. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-425
     February 28, 2024 - Adverse safety events in emergency medical services care of children with out-of-hospital cardiac … Adverse safety events (ASE) are common in pediatric out-of-hospital cardiac arrests (OHCA). … Adverse safety events (ASE) are common in pediatric out-of-hospital cardiac arrests (OHCA). … This analysis examines a case of communication failure during cardiac telemetry processes that resulted … The patient went into cardiac arrest and ultimately passed away.

424. Reduction of medication errors related to sliding scale insulin by the introduction of a standardized order sheet. | PSNet
     psnet.ahrq.gov/issue/reduction-medication-errors-related-sliding-scale-insulin-introduction-standardized-order
     June 19, 2024 - September 13, 2023 Hospital-acquired functional decline and clinical outcomes in older cardiac … Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49576/psn-pdf
     January 01, 2009 - Despite maximal efforts, the patient eventually died from a cardiac arrest. … considered Hospital Y the closest appropriate facility because it had better capabilities (such as cardiac … bypass local hospitals to bring patients to Level I trauma centers, stroke centers, or centers with cardiac … considered the ability to provide therapeutic hypothermia after return of spontaneous circulation in cardiac … City pushes cooling therapy for cardiac arrest. The New York Times. December 3, 2008.

426. Improving teamwork in healthcare: current approaches and the path forward. | PSNet
     psnet.ahrq.gov/issue/improving-teamwork-healthcare-current-approaches-and-path-forward
     February 12, 2020 - 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. … June 29, 2022 WebM&M Cases Management of Cardiac Arrest

427. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
     January 01, 2021 - surgery, resulting in postoperative hypotension despite a normal or increased cardiac index • Most … Postoperative complications among patients undergoing cardiac surgery. … Management of vasodilatory shock after cardiac surgery: identification of predisposing factors and use … Vasopressin versus norepinephrine in patients with vasoplegic shock after cardiac surgery: the VANCS … Effect of perioperative goal-directed hemodynamic resuscitation therapy on outcomes following cardiac

428. The Deadly Duo | PSNet
     psnet.ahrq.gov/web-mm/deadly-duo
     April 28, 2021 - other drugs.( 24 ) The most dreaded toxicity of TCAs derives from their multiple effects on the cardiac … These changes may lead to increased cardiac morbidity and mortality in one of four scenarios: (i) when … administered to a patient with pre-existing cardiac problems (e.g., bundle-branch block, third-degree … (ii) when ingested in an overdose; (iii) when administered along with other agents that also affect cardiac … increasing the likelihood of occurrence and the severity of the same when they do occur—such as the cardiac

429. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33807/psn-pdf
     May 01, 2016 - I first started with cardiac monitoring clinically way back in the late 1960s, when I was a student … BD: I have been in this cardiac monitoring business for over 40 years. … But nurses have been living with this, and they often say to me, "And those are just the cardiac monitor … I'm trying to encourage the cardiac monitoring companies to build more intuitive devices because we … Many of those patients are also on cardiac monitors, and there are fewer nurses per patient.

430. Perspectives on perioperative team-based morbidity and mortality conferences: a mixed-methods study. | PSNet
     psnet.ahrq.gov/issue/perspectives-perioperative-team-based-morbidity-and-mortality-conferences-mixed-methods-study
     October 11, 2023 - Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac … May 26, 2021 Independent Mortality Review of Cardiac Surgery at St George’s University

431. Improving patients' intensive care admission through multidisciplinary simulation-based crisis resource management: a qualitative study. | PSNet
     psnet.ahrq.gov/issue/improving-patients-intensive-care-admission-through-multidisciplinary-simulation-based-crisis
     August 23, 2023 - September 13, 2023 In-situ simulations to detect patient safety threats during in-hospital cardiac … September 13, 2023 Video review of simulated pediatric cardiac arrest to identify errors

432. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74251/psn-pdf
     January 26, 2022 - 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 … conditions than during active cardiopulmonary resuscitation), would have likely prevented the patient’s cardiac … Prospective analysis of percutaneous central venous catheterization in infants <4.0 kg undergoing cardiac

433. Timeout procedure in paediatric surgery: effective tool or lip service? A randomised prospective observational study. | PSNet
     psnet.ahrq.gov/issue/timeout-procedure-paediatric-surgery-effective-tool-or-lip-service-randomised-prospective
     April 06, 2022 - November 28, 2016 Application of the aviation black box principle in pediatric cardiac … surgery: tracking all failures in the pediatric cardiac operating room.

434. Missed diagnosis of new-onset systolic heart failure at first presentation in children with no known heart disease. | PSNet
     psnet.ahrq.gov/issue/missed-diagnosis-new-onset-systolic-heart-failure-first-presentation-children-no-known-heart
     August 18, 2021 - National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac … February 3, 2011 A reduction in cardiac arrests and duration of clinical instability

435. Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. | PSNet
     psnet.ahrq.gov/issue/incidence-and-root-cause-analysis-wrong-site-pain-management-procedures-multicenter-study
     April 29, 2020 - , 2022 How strong is the evidence for the use of perioperative beta blockers in non-cardiac … July 17, 2024 Survival from in-hospital cardiac arrest during nights and weekends.

436. Association of measured quality with financial health among U.S. hospitals. | PSNet
     psnet.ahrq.gov/issue/association-measured-quality-financial-health-among-us-hospitals
     December 07, 2022 - Association of measured quality and future financial performance among hospitals performing cardiac … Association of measured quality and future financial performance among hospitals performing cardiac

437. Postdischarge adverse events among neonates admitted to the neonatal intensive care unit. | PSNet
     psnet.ahrq.gov/issue/postdischarge-adverse-events-among-neonates-admitted-neonatal-intensive-care-unit
     October 05, 2022 - July 15, 2020 A handoff protocol from the cardiovascular operating room to cardiac ICU … Cases Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac

438. Changing hospital organisational culture for improved patient outcomes: developing and implementing the Leadership Saves Lives intervention. | PSNet
     psnet.ahrq.gov/issue/changing-hospital-organisational-culture-improved-patient-outcomes-developing-and
     June 17, 2020 - Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac … April 6, 2022 Hospital-acquired functional decline and clinical outcomes in older cardiac

439. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. | PSNet
     psnet.ahrq.gov/issue/use-design-thinking-and-human-factors-approach-improve-situation-awareness-pediatric
     January 19, 2022 - 2021 Transparency, public reporting, and a culture of change to quality and safety in cardiac … September 20, 2023 Video review of simulated pediatric cardiac arrest to identify errors

440. Management of the deteriorating adult patient: does simulation-based education improve patient safety? | PSNet
     psnet.ahrq.gov/issue/management-deteriorating-adult-patient-does-simulation-based-education-improve-patient-safety
     June 08, 2022 - Download Citation Related Resources From the Same Author(s) Hospital-wide cardiac … September 13, 2023 Video review of simulated pediatric cardiac arrest to identify errors