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psnet.ahrq.gov/issue/patient-error-preliminary-taxonomy
June 02, 2010 - April 9, 2009
Post-discharge medication reviews for patients with heart failure: a pilot
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - SPOTLIGHT CASE
Harm From Alarm Fatigue
Citation Text:
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49454/psn-pdf
July 01, 2004 - aspirin and beta-blockers in coronary artery disease
and angiotensin-converting enzyme inhibitors in congestive … heart failure (15), failure to treat must be
viewed as a medication error that leads to unnecessary
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - noncardiac surgery found that the factors most consistently predictive of adverse cardiac outcomes were heart … failure, type of surgery, serum creatinine, diabetes, history of stroke or transient ischemic attack
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psnet.ahrq.gov/issue/model-recovering-medical-errors-coronary-care-unit
June 02, 2010 - Study
A model of recovering medical errors in the coronary care unit.
Citation Text:
Hurley A, Rothschild JM, Moore ML, et al. A model of recovering medical errors in the coronary care unit. Heart Lung. 2008;37(3):219-26. doi:10.1016/j.hrtlng.2007.06.002.
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psnet.ahrq.gov/node/49563/psn-pdf
May 01, 2008 - https://psnet.ahrq.gov/web-mm/it-safe-be-direct
The Case
A 92-year-old man with hypertension and heart … failure (HF) was evaluated by his primary care physician
(PCP) for progressive shortness of breath
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psnet.ahrq.gov/issue/distractions-cardiac-catheterisation-laboratory-impact-cardiologists-and-patient-safety
June 07, 2023 - Study
Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety.
Citation Text:
Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. Open Heart. 2020;7(2). doi:…
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psnet.ahrq.gov/issue/surgeon-reported-conflict-intensivists-about-postoperative-goals-care
September 26, 2012 - Study
Surgeon-reported conflict with intensivists about postoperative goals of care.
Citation Text:
Olson TJP, Brasel KJ, Redmann AJ, et al. Surgeon-reported conflict with intensivists about postoperative goals of care. JAMA Surg. 2013;148(1):29-35. doi:10.1001/jamasurgery.2013.403.
Co…
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Right Electrocardiogram, Wrong Patient
March 25, 2020
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
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psnet.ahrq.gov/issue/advancing-health-equity-patient-safety-reckoning-challenge-and-opportunity
February 23, 2022 - Commentary
Advancing health equity in patient safety: a reckoning, challenge and opportunity.
Citation Text:
Chin MH. Advancing health equity in patient safety: a reckoning, challenge and opportunity. BMJ Qual Saf. 2021;30(5):356-361. doi:10.1136/bmjqs-2020-012599.
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psnet.ahrq.gov/issue/postoperative-handover-problems-pitfalls-and-prevention-error
September 26, 2012 - Image/Poster
Postoperative handover: problems, pitfalls, and prevention of error.
Citation Text:
Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error. Ann Surg. 2010;252(1):171-6. doi:10.1097/SLA.0b013e3181dc3656.
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…
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psnet.ahrq.gov/node/866395/psn-pdf
July 23, 2024 - Rescue Improvement Conference Innovation Summary
July 23, 2024
https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
Summary
The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure
to rescue with a particular focus on communication and com…
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - Case & Commentary—Part 1
A 51-year-old man with history of congestive heart failure (ejection fraction
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psnet.ahrq.gov/node/60039/psn-pdf
March 11, 2020 - A 25-year-old teacher died after waiting hours at the ER.
She's not the only one who saw delays.
March 11, 2020
Linnane R, Diedrich J. Milwaukee Journal Sentinel. February 25, 2020.
https://psnet.ahrq.gov/issue/25-year-old-teacher-died-after-waiting-hours-er-shes-not-only-one-who-saw-
delays
Delays in emergency r…
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psnet.ahrq.gov/issue/systems-approach-analyzing-and-preventing-hospital-adverse-events
March 30, 2022 - Study
Emerging Classic
A systems approach to analyzing and preventing hospital adverse events.
Citation Text:
Leveson N, Samost A, Dekker SWA, et al. A systems approach to analyzing and preventing hospital adverse events. J Patient Saf. 2020;16(2):162-167. doi:1…
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psnet.ahrq.gov/issue/my-patient-ready-safe-transfer-lower-intensity-care-setting-nursing-complexity-independent
April 26, 2023 - Study
Is my patient ready for a safe transfer to a lower-intensity care setting? Nursing complexity as an independent predictor of adverse events risk after ICU discharge.
Citation Text:
Sanson G, Marino C, Valenti A, et al. Is my patient ready for a safe transfer to a lower-intensity ca…
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psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
August 15, 2017 - Perils in Diagnosing a Stroke
Citation Text:
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/issue/effect-hospital-wide-measure-readmissions-reduction-program
February 14, 2017 - Study
Effect of a hospital-wide measure on the readmissions reduction program.
Citation Text:
Zuckerman RB, Maddox KEJ, Sheingold SH, et al. Effect of a Hospital-wide Measure on the Readmissions Reduction Program. N Engl J Med. 2017;377(16):1551-1558. doi:10.1056/NEJMsa1701791.
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psnet.ahrq.gov/issue/mortality-due-hospital-acquired-infection-after-cardiac-surgery
February 12, 2020 - Study
Mortality due to hospital-acquired infection after cardiac surgery.
Citation Text:
Massart N, Mansour A, Ross JT, et al. Mortality due to hospital-acquired infection after cardiac surgery. J Thorac Cardiovasc Surg. 2022;163(6):2131-2140.e3. doi:10.1016/j.jtcvs.2020.08.094.
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psnet.ahrq.gov/node/46911/psn-pdf
May 02, 2018 - Errors in electronic health record–based data query of
statin prescriptions in patients with coronary artery
disease in a large, academic, multispecialty clinic
practice.
May 2, 2018
Shin EY, Ochuko P, Bhatt K, et al. Errors in Electronic Health Record-Based Data Query of Statin
Prescriptions in Patients With Cor…