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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - SPOTLIGHT CASE
Unexplained Apnea Under Anesthesia
Citation Text:
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care
November 16, 2022 - Study
The Human Factors Analysis Classification System (HFACS) applied to health care.
Citation Text:
Diller T, Helmrich G, Dunning S, et al. The Human Factors Analysis Classification System (HFACS) applied to health care. Am J Med Qual. 2014;29(3):181-190. doi:10.1177/1062860613491623. …
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psnet.ahrq.gov/issue/diagnostic-errors-paediatric-cardiac-intensive-care
June 24, 2020 - Study
Diagnostic errors in paediatric cardiac intensive care.
Citation Text:
Bhat PN, Costello JM, Aiyagari R, et al. Diagnostic errors in paediatric cardiac intensive care. Cardiol Young. 2018;28(5):675-682. doi:10.1017/S1047951117002906.
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DOI Google S…
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psnet.ahrq.gov/issue/new-perspective-blame-culture-experimental-study
July 10, 2013 - Study
A new perspective on blame culture: an experimental study.
Citation Text:
Gorini A, Miglioretti M, Pravettoni G. A new perspective on blame culture: an experimental study. J Eval Clin Pract. 2012;18(3):671-5. doi:10.1111/j.1365-2753.2012.01831.x.
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psnet.ahrq.gov/issue/relationship-between-preventability-death-after-coronary-artery-bypass-graft-surgery-and-all
September 23, 2020 - Study
Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates.
Citation Text:
Guru V, Tu J, Etchells E, et al. Relationship between preventability of death after coronary artery bypass graft surgery and all-cau…
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psnet.ahrq.gov/issue/novel-approach-assessing-bias-during-team-based-clinical-decision-making
April 10, 2024 - Study
A novel approach for assessing bias during team-based clinical decision-making.
Citation Text:
Pool N, Hebdon M, de Groot E, et al. A novel approach for assessing bias during team-based clinical decision-making. Front in Public Health. 2023;11:1014773. doi:10.3389/fpubh.2023.101477…
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psnet.ahrq.gov/issue/recommendations-british-committee-standards-haematology-and-national-patient-safety-agency
November 12, 2014 - Organizational Policy/Guidelines
Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency.
Citation Text:
Baglin TP, Cousins D, Keeling DM, et al. Safety indicators for inpatient and outpatient oral anticoagulant care: [corrected] Recom…
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psnet.ahrq.gov/issue/effects-electrode-misplacement-clinicians-interpretation-standard-12-lead-electrocardiogram
February 10, 2016 - Study
The effects of electrode misplacement on clinicians' interpretation of the standard 12-lead electrocardiogram.
Citation Text:
Bond RR, Finlay DD, Nugent CD, et al. The effects of electrode misplacement on clinicians' interpretation of the standard 12-lead electrocardiogram. Eur J…
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psnet.ahrq.gov/issue/leder-learning-lives-and-deaths
October 19, 2022 - Multi-use Website
LeDeR - Learning from Lives and Deaths.
Citation Text:
LeDeR - Learning from Lives and Deaths. Norah Frye Centre for Disability Studies; Bristol, England.
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psnet.ahrq.gov/issue/time-out-professional-and-organizational-ethics-speaking-or
November 08, 2017 - Commentary
Time-out: the professional and organizational ethics of speaking up in the OR.
Citation Text:
Berlinger N, Dietz E. Time-out: The Professional and Organizational Ethics of Speaking Up in the OR. AMA J Ethics. 2016;18(9):925-32. doi:10.1001/journalofethics.2016.18.9.stas1-1609.…
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psnet.ahrq.gov/issue/promoting-engagement-patients-and-families-reduce-adverse-events-acute-care-settings
July 02, 2014 - Review
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
Citation Text:
Berger ZD, Flickinger TE, Pfoh ER, et al. Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic …
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psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - The Case
A 94-year-old woman with history of congestive heart failure (CHF), hypertension, and gout
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hcup-us.ahrq.gov/db/nation/nrd/stats/NRD_2012_MaskedStats_Core_V2_Weighted.PDF
January 01, 2012 - SUBACUTE ENDOCARDITIS W CC 2,832 0.01%
290: ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC 760 0.00%
291: HEART … FAILURE & SHOCK W MCC 300,722 0.82%
292: HEART FAILURE & SHOCK W CC 371,834 1.02%
293: HEART FAILURE … Cardiac dysrhythmias 749,595 2.06%
107: Cardiac arrest and ventricular fibrillation 18,254 0.05%
108: Congestive … heart failure; nonhypertensive 882,215 2.42%
109: Acute cerebrovascular disease 569,661 1.56%
110:
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hcup-us.ahrq.gov/db/nation/nrd/stats/NRD_2012_MaskedStats_Core_V2.PDF
January 01, 2012 - SUBACUTE ENDOCARDITIS W CC 1,173 0.01%
290: ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC 319 0.00%
291: HEART … FAILURE & SHOCK W MCC 122,695 0.91%
292: HEART FAILURE & SHOCK W CC 150,762 1.12%
293: HEART FAILURE … Cardiac dysrhythmias 301,482 2.24%
107: Cardiac arrest and ventricular fibrillation 7,316 0.05%
108: Congestive … heart failure; nonhypertensive 356,363 2.65%
109: Acute cerebrovascular disease 233,898 1.74%
110:
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hcup-us.ahrq.gov/db/nation/nrd/stats/NRD_2011_MaskedStats_Core_V2.PDF
January 01, 2011 - SUBACUTE ENDOCARDITIS W CC 1,214 0.01%
290: ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC 368 0.00%
291: HEART … FAILURE & SHOCK W MCC 122,537 0.88%
292: HEART FAILURE & SHOCK W CC 159,839 1.15%
293: HEART FAILURE … Cardiac dysrhythmias 306,153 2.20%
107: Cardiac arrest and ventricular fibrillation 7,353 0.05%
108: Congestive … heart failure; nonhypertensive 377,856 2.72%
109: Acute cerebrovascular disease 235,751 1.69%
110:
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hcup-us.ahrq.gov/db/nation/nrd/stats/NRD_2011_MaskedStats_Core_V2_Weighted.PDF
January 01, 2011 - SUBACUTE ENDOCARDITIS W CC 2,776 0.01%
290: ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC 861 0.00%
291: HEART … FAILURE & SHOCK W MCC 293,161 0.79%
292: HEART FAILURE & SHOCK W CC 383,832 1.04%
293: HEART FAILURE … Cardiac dysrhythmias 746,160 2.02%
107: Cardiac arrest and ventricular fibrillation 17,353 0.05%
108: Congestive … heart failure; nonhypertensive 910,358 2.47%
109: Acute cerebrovascular disease 562,665 1.52%
110:
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hcup-us.ahrq.gov/db/nation/nrd/stats/NRD_2010_MaskedStats_Core_V2.PDF
January 01, 2010 - SUBACUTE ENDOCARDITIS W CC 1,157 0.01%
290: ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC 378 0.00%
291: HEART … FAILURE & SHOCK W MCC 146,272 1.05%
292: HEART FAILURE & SHOCK W CC 137,115 0.99%
293: HEART FAILURE … Cardiac dysrhythmias 312,045 2.24%
107: Cardiac arrest and ventricular fibrillation 6,865 0.05%
108: Congestive … heart failure; nonhypertensive 390,819 2.81%
109: Acute cerebrovascular disease 231,735 1.67%
110:
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hcup-us.ahrq.gov/db/nation/nrd/stats/NRD_2010_MaskedStats_Core_V2_Weighted.PDF
January 01, 2010 - SUBACUTE ENDOCARDITIS W CC 2,642 0.01%
290: ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC 874 0.00%
291: HEART … FAILURE & SHOCK W MCC 348,675 0.94%
292: HEART FAILURE & SHOCK W CC 330,989 0.89%
293: HEART FAILURE … Cardiac dysrhythmias 765,325 2.05%
107: Cardiac arrest and ventricular fibrillation 17,090 0.05%
108: Congestive … heart failure; nonhypertensive 942,667 2.53%
109: Acute cerebrovascular disease 553,629 1.48%
110:
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hcup-us.ahrq.gov/reports/statbriefs/sb73.pdf
May 01, 2009 - complications (77 percent higher), chronic obstructive pulmonary disease (COPD) (69 percent higher), and
congestive … heart failure (51 percent higher).
2 Prevention … others
Rank
(other
areas)
1 Newborn infants 155.6 136.1 14% 1
2 Pneumonia 51.4 36.1 42% 3
3 Congestive … heart failure
(CHF) 48.2 32.0 51% 4
4
Coronary
atherosclerosis
(hardening of the
arteries)