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psnet.ahrq.gov/node/841799/psn-pdf
August 14, 2023 - Diagnostic Errors in the Emergency Department: A
Systematic Review.
December 21, 2022
Newman-Toker DE, Peterson SM, Badihian S, et al. Rockville, MD: Agency for Healthcare Research and
Quality; December 2022. AHRQ Publication No. 22(23)-EHC043.
https://psnet.ahrq.gov/issue/diagnostic-errors-emergency-departme…
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hcup-us.ahrq.gov/db/nation/nis/tools/stats/NIS_2006_MaskedStats_Severity.PDF
January 01, 2006 - measure: Chronic blood loss anemia 8074825 0 0.00 1.00 0.02 0.14
CM_CHF : AHRQ comorbidity measure: Congestive … heart failure 8074825 0 0.00 1.00 0.06 0.24
CM_CHRNLUNG : AHRQ comorbidity measure: Chronic pulmonary … FAILURE OR SHOCK 2342 0.03
171: PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK 31107 … FAILURE & SHOCK WO CC 32854 0.41
1271: HEART FAILURE & SHOCK W CC 120548 1.49
1272: HEART FAILURE … Heart Failure 20610 0.26
CVS10: Coronary Artery Disease with Prior Coronary Revascularization 82573
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hcup-us.ahrq.gov/db/nation/nis/tools/stats/NIS_2004_SummaryStats_SEVERITY.PDF
January 01, 2004 - measure: Chronic
blood loss anemia 8004571 0 0.00 1.00 0.02 0.14
CM_CHF : AHRQ comorbidity measure: Congestive … heart
failure 8004571 0 0.00 1.00 0.06 0.24
CM_CHRNLUNG : AHRQ comorbidity measure: Chronic
pulmonary … FAILURE OR
SHOCK
3619 0.05
171: PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK 29837 … FAILURE & SHOCK W/O CC 45661 0.57
1271: HEART FAILURE & SHOCK W CC 121812 1.52
1272: HEART FAILURE … Heart Failure 35621 0.45
CVS10: Coronary Artery Disease Prior Coronary Revascularization 78454 0.98
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hcup-us.ahrq.gov/db/nation/nis/tools/stats/NIS_2005_SummaryStats_SEVERITY.PDF
January 01, 2005 - measure: Chronic
blood loss anemia 7995048 0 0.00 1.00 0.02 0.14
CM_CHF : AHRQ comorbidity measure: Congestive … heart
failure 7995048 0 0.00 1.00 0.06 0.24
CM_CHRNLUNG : AHRQ comorbidity measure: Chronic
pulmonary … FAILURE OR
SHOCK
2643 0.03
171: PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK 29739 … FAILURE & SHOCK WO CC 40161 0.50
1271: HEART FAILURE & SHOCK W CC 118271 1.48
1272: HEART FAILURE … Heart Failure 21265 0.27
CVS10: Coronary Artery Disease Prior Coronary Revascularization 78236 0.98
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_111.pdf
June 18, 2008 - If a patient shows signs or
symptoms of congestive heart failure,
SpO2 monitoring is required and a … vein thrombosis; COPD = chronic
obstructive pulmonary disease; OSA = obstructive sleep apnea;
CHF = congestive … heart failure)
Results
PCA Infusion Programming: Averted Errors
During the initial 4 months, IV
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psnet.ahrq.gov/issue/role-surgeon-error-withdrawal-postoperative-life-support
July 03, 2014 - Study
The role of surgeon error in withdrawal of postoperative life support.
Citation Text:
Schwarze ML, Redmann AJ, Brasel KJ, et al. The role of surgeon error in withdrawal of postoperative life support. Ann Surg. 2012;256(1):10-5. doi:10.1097/SLA.0b013e3182580de5.
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psnet.ahrq.gov/issue/standardized-postoperative-handover-process-improves-outcomes-intensive-care-unit-model
June 21, 2015 - Study
Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance.
Citation Text:
Bhakta RT, Stockwell DC. Transitions of care in the pediatric cardiac intensive care unit*. Crit Care Med…
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psnet.ahrq.gov/issue/supervision-autonomy-and-medical-error-teaching-clinic
November 26, 2014 - Commentary
Supervision, autonomy, and medical error in the teaching clinic.
Citation Text:
Cossman JP, Wang M, Fischer AA. Supervision, autonomy, and medical error in the teaching clinic. J Am Acad Dermatol. 2018;79(5):981-983. doi:10.1016/j.jaad.2017.12.033.
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Format: …
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www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/advocacy.html
June 01, 2023 - Tool: Advocacy and Assertion
Providing mutual support also sometimes requires the use of advocacy and assertion. Advocacy and assertion interventions are invoked when a team member's viewpoint does not coincide with that of a decision maker. In advocating by or for the patient and asserting the need for correct…
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psnet.ahrq.gov/issue/ash-clinical-practice-guidelines-venous-thromboembolism
September 14, 2007 - Clinical Guideline
ASH Clinical Practice Guidelines on Venous Thromboembolism.
Citation Text:
ASH Clinical Practice Guidelines on Venous Thromboembolism. Washington DC; American Society of Hematology.
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psnet.ahrq.gov/issue/patient-safety-7
November 16, 2015 - Book/Report
Patient Safety.
Citation Text:
Patient Safety. Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
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psnet.ahrq.gov/issue/patient-alarms-often-unheard-unheeded
August 24, 2016 - Newspaper/Magazine Article
Patient alarms often unheard, unheeded.
Citation Text:
Patient alarms often unheard, unheeded. Kowalczyk L. Boston Globe. February 13–14, 2011.
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www.ahrq.gov/topics/sepsis.html
Topic: Sepsis
AHRQ provides several resources to address sepsis, a systemic inflammatory response to infection that results in tissue damage and organ failure that can lead to death. It is one of the most expensive and difficult to treat conditions in hospitals in the United States. The fiscal year 2023 Omnibus Spend…
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hcup-us.ahrq.gov/datainnovations/grants.jsp
July 01, 2016 - compilation of study data
Developed hospital reports on data quality (including present-on-admission and congestive … heart failure cases), individual recommendations about the pharmacological management of ADHF (Acute … Decompensated Heart Failure) patients, and risk-adjusted clinical outcomes comparing other participating
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/Rm4E5SooP2GnqJ_HVRA5M4
January 01, 2017 - related mortality,145 nonfatal cardiovascular events,12 heart
failure,148 coronary heart disease,148 … Auto-titrating continuous positive airway pressure
therapy in patients with chronic heart failure and … Sustained effect of continuous
positive airway pressure on baroreflex sensitivity in
congestive heart … Inhibition of
awake sympathetic nerve activity of heart failure
patients with obstructive sleep apnea … Prospective study of obstructive sleep apnea and
incident coronary heart disease and heart failure:
the
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/preterm-birth-terbutaline-pump_research-protocol.pdf
October 18, 2010 - i. women with RPTL and women without RPTL
KQ3: increase the maternal harms of pulmonary edema, heart … failure, arrhythmia,
myocardial infarction, refractory hypotension, hypokalemia, hyperglycemia, and … failure
• Arrhythmia
• Myocardial infarction
• Hypotension
• Hypokalemia
• Hyperglycemia
• WDAE … for oxygen per nasal cannula
• NICU admission
Outcomes –
maternal harms
• Pulmonary edema
• Heart … failure, arrhythmia, myocardial infarction,
refractory hypotension, hypokalemia, and hyperglycemia,
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effectivehealthcare.ahrq.gov/health-topics/diabetic-heart-disease
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psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
April 24, 2024 - Right Electrocardiogram, Wrong Patient
Citation Text:
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology-cardiovascular
January 06, 2012 - Study
Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room.
Citation Text:
Elbardissi AW, Wiegmann DA, Dearani JA, et al. Application of the human factors analysis and classification system methodology to the cardi…
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psnet.ahrq.gov/node/41763/psn-pdf
October 10, 2012 - Latency of ECG displays of hospital telemetry systems: a
science advisory from the American Heart Association.
October 10, 2012
Turakhia MP, Estes NAM, Drew BJ, et al. Latency of ECG displays of hospital telemetry systems: a science
advisory from the American Heart Association. Circulation. 2012;126(13):1665-9.
ht…