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psnet.ahrq.gov/issue/measurement-adverse-events-using-incidence-flagged-diagnosis-codes
June 18, 2013 - October 8, 2016
Misdiagnosis of heart failure: a systematic review of the literature.
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psnet.ahrq.gov/issue/power-saying-i-dont-know-psychological-safety-and-participatory-strategies-healthcare-leaders
August 31, 2011 - adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart … failure.
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psnet.ahrq.gov/issue/doctors-were-alarmed-would-i-have-my-children-have-surgery-here
February 19, 2020 - May 29, 2019
Heart Failure: The Decline of a Historic Transplant Program.
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psnet.ahrq.gov/issue/placing-patient-safety-heart-value-based-healthcare
February 15, 2023 - Commentary
Placing patient safety at the heart of value-based healthcare.
Citation Text:
La Regina M, Federici L, Bianco A, et al. Placing patient safety at the heart of value-based healthcare. Int J Qual Health Care. 2024;36(3):mzae087. doi:10.1093/intqhc/mzae087.
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Fo…
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psnet.ahrq.gov/node/41526/psn-pdf
April 05, 2013 - within one month following discharge for an episode of acute
coronary syndrome or acute decompensated heart … failure.
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psnet.ahrq.gov/periodic-issue/periodic-issue-469
December 31, 2024 - WebM&Ms
WebM&M Cases
Spotlight Case
Mismanagement of Acute Decompensated Heart … Failure with Hypertensive Emergency Jaenic Lee, MD, Josh Fernelius, MD and William Frick, MD | December … Diagnostic tests revealed acute heart failure exacerbation with pulmonary edema, marked elevation of … commentary discusses the contraindications for beta-blockers in the setting of acute decompensated heart … failure and appropriate treatment for hypertensive emergencies in the emergency department and intensive
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psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
August 21, 2005 - fibrillation, history of a stroke or TIA, or risk factor(s) for stroke, such as hypertension, diabetes, congestive … heart failure, or age >75 years.
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psnet.ahrq.gov/issue/better-nurse-staffing-associated-survival-black-patients-and-diminishes-racial-disparities
June 02, 2021 - 2021
The quality of hospital work environments and missed nursing care is linked to heart … failure readmissions: a cross-sectional study of US hospitals.
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psnet.ahrq.gov/issue/analysis-hospital-level-readmission-rates-and-variation-adverse-events-among-patients
August 25, 2021 - adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart … failure.
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psnet.ahrq.gov/issue/effects-nurse-patient-ratio-legislation-nurse-staffing-and-patient-mortality-readmissions-and
September 09, 2020 - 2011
The quality of hospital work environments and missed nursing care is linked to heart … failure readmissions: a cross-sectional study of US hospitals.
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psnet.ahrq.gov/issue/what-new-doctor-learned-about-medical-mistakes-her-moms-death
March 03, 2021 - July 5, 2023
Heart Failure: The Decline of a Historic Transplant Program.
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psnet.ahrq.gov/web-mm/bowel-prep
March 01, 2017 - Oral sodium phosphate preparations should not be used in patients with renal disease, congestive heart … failure, or ascites.( 3 ) A meta-analysis of eight randomized trials comprising 1286 subjects suggested … of the medical conditions that would preclude the use of this agent, such as renal insufficiency or heart … failure.
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psnet.ahrq.gov/issue/safety-events-pediatric-out-hospital-cardiac-arrest
August 01, 2018 - April 28, 2021
Missed diagnosis of new-onset systolic heart failure at first presentation
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psnet.ahrq.gov/node/49456/psn-pdf
July 12, 2004 - https://psnet.ahrq.gov/web-mm/glucose-roller-coaster
The Case
A 71-year-old woman with congestive heart … failure was admitted to the hospital. … it is
not surprising that a busy intern with limited or inadequate knowledge of a 71-year-old with heart … failure
would be tempted to manage her care with reflexive verbal orders without a more thorough evaluation
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psnet.ahrq.gov/node/45892/psn-pdf
October 31, 2017 - evidence-based actions were appropriately taken for common conditions like myocardial infarction,
pneumonia, heart … failure, and surgical care; patient experience as measured by the Hospital Consumer
Assessment of Healthcare
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psnet.ahrq.gov/issue/heart-health-care-parents-perspectives-patient-safety
April 24, 2018 - Commentary
The heart of health care: parents' perspectives on patient safety.
Citation Text:
Micalizzi DA, Bismark M. The heart of health care: parents' perspectives on patient safety. Pediatr Clin North Am. 2012;59(6):1233-1246. doi:10.1016/j.pcl.2012.08.004.
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Format:…
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only
Spotlight
Delay in Appropriate Diagnosis and
Treatment Leading to Death from
Pulmonary Embolism
Source and Credits
• This presentation is based on the February 2021 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/issue/application-aviation-black-box-principle-pediatric-cardiac-surgery-tracking-all-failures
October 07, 2013 - Study
Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.
Citation Text:
Bowermaster R, Miller M, Ashcraft T, et al. Application of the aviation black box principle in pediatric cardiac surgery: trac…
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psnet.ahrq.gov/issue/educational-levels-hospital-nurses-and-surgical-patient-mortality
February 09, 2011 - 2018
The quality of hospital work environments and missed nursing care is linked to heart … failure readmissions: a cross-sectional study of US hospitals.
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psnet.ahrq.gov/issue/less-more-project-reduce-number-pims-potentially-inappropriate-medications-elderly-care-ward
September 27, 2017 - Author(s)
The quality of hospital work environments and missed nursing care is linked to heart … failure readmissions: a cross-sectional study of US hospitals.