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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/expanding-cardiac-rehab-implementation-guide.pdf
December 01, 2022 - failure patients, patients treated elsewhere). … Do you have strong
financial incentives to
High readmission rates for AMI or heart failure can impact … failure may require facility-based supervision and monitoring due to blood
pressure, EKG, or physical … failure patients)
• levels of exercise intensity
Data Capture
Some, but not all, programs provide … Efficacy and safety of exercise training in patients with chronic heart failure: HF-
ACTION randomized
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psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
June 24, 2020 - requirements include a body mass index (BMI) less than 20, liver disease (including passive congestion from congestive … heart failure), and being treated with a drug that inhibits warfarin metabolism (eg, metronidazole,
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psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
June 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment
Citation Text:
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. 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/node/49556/psn-pdf
March 01, 2008 - Hold That Order
March 1, 2008
Grissinger M. Hold That Order. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/hold-order
The Case
A 25-year-old woman with a history of a pituitary tumor was admitted with hypernatremia. Because of her
previous pituitary resection and radiation, the patient had a long history …
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psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
July 01, 2003 - DNR in the OR and Afterwards
Citation Text:
Lo B. DNR in the OR and Afterwards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/issue/simulation-graduate-medical-education-2008-review-emergency-medicine
July 13, 2010 - Commentary
Simulation in graduate medical education 2008: a review for emergency medicine.
Citation Text:
McLaughlin S, Fitch MT, Goyal DG, et al. Simulation in graduate medical education 2008: a review for emergency medicine. Acad Emerg Med. 2008;15(11):1117-29. doi:10.1111/j.1553-271…
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www.ahrq.gov/hai/cusp/toolkit/daily-goals.html
December 01, 2012 - Daily Goals Checklist
CUSP Toolkit
Effective communication is particularly important in the unit if complicated care plans are to be effectively managed by the care team
Problem statement: Clear communication among health care providers is paramount. Communication failures lead to patient harm, increased l…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/dailygoals.docx
January 01, 2003 - Daily Goals Checklist
Problem statement: Clear communication among health care providers is paramount. Communication failures lead to patient harm, increased length of stay, provider dissatisfaction, and staff turnover. Effective communication is particularly important in the unit if complicated care plans are to be …
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psnet.ahrq.gov/issue/accuracy-interpretation-preparticipation-screening-electrocardiograms
May 18, 2022 - Study
Accuracy of interpretation of preparticipation screening electrocardiograms.
Citation Text:
Hill AC, Miyake CY, Grady S, et al. Accuracy of interpretation of preparticipation screening electrocardiograms. J Pediatr. 2011;159(5):783-8. doi:10.1016/j.jpeds.2011.05.014.
Copy Citat…
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psnet.ahrq.gov/issue/intraoperative-handoffs-among-anesthesia-providers-increase-incidence-documentation-errors
April 12, 2019 - Study
Intraoperative handoffs among anesthesia providers increase the incidence of documentation errors for controlled drugs.
Citation Text:
Epstein RH, Dexter F, Gratch DM, et al. Intraoperative Handoffs Among Anesthesia Providers Increase the Incidence of Documentation Errors for Contr…
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psnet.ahrq.gov/issue/hospitals-cultures-entrapment-re-analysis-bristol-royal-infirmary
May 21, 2019 - Commentary
Classic
Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary.
Citation Text:
Weick KE, Sutcliffe KM. Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary. Calif Manage Rev. 2012;45(2):73-84. do…
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psnet.ahrq.gov/issue/impact-anesthetic-handover-mortality-and-morbidity-cardiac-surgery-cohort-study
August 04, 2021 - Study
Impact of anesthetic handover on mortality and morbidity in cardiac surgery: a cohort study.
Citation Text:
Hudson CCC, McDonald B, Hudson JKC, et al. Impact of anesthetic handover on mortality and morbidity in cardiac surgery: a cohort study. J Cardiothorac Vasc Anesth. 2015;29(1)…
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
November 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Errors Case Studies
Download
Share
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Subscribe
Created By: Maria Mirica, PRIDE Group
…
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hcup-us.ahrq.gov/db/nation/nrd/NRD_Introduction_2013.jsp
January 01, 2013 - Consider the following example:
A patient with congestive heart failure has a 3-day hospital admission … heart failure: (1) comorbidity present, (0) comorbidity not present
CM_CHRNLUNG
AHRQ comorbidity … heart failure; nonhypertensive
468,709
25.05
25.70
2.6
122: Pneumonia (except that caused … 107: Cardiac arrest and ventricular fibrillation
3,236
18.88
19.96
5.7
108: Congestive … heart failure; nonhypertensive
468,709
25.05
25.70
2.6
109: Acute cerebrovascular disease
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/painmgmt-slides.pptx
January 01, 2017 - Dre
Diseases
Sepsis, chronic obstructive pulmonary disease, congestive heart failure
Drug Removal
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-guidance-tests-search_methods.pdf
July 01, 2012 - In the AHRQ report,
Testing for BNP and NT-proBNP in the Diagnosis and Prognosis of Heart Failure,25 … Balion, C., et al., Testing for BNP and NT-
proBNP in the Diagnosis and Prognosis of
Heart Failure.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/cap-guide.docx
September 01, 2022 - To summarize the PSI score, patients younger than 50; without a history of neoplastic disease, congestive … heart failure, cerebrovascular disease, renal disease, or liver disease; at their baseline mental status
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psnet.ahrq.gov/node/49729/psn-pdf
April 01, 2015 - Dissecting the Presentation
April 1, 2015
Suat-Ooi SB. Dissecting the Presentation. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/dissecting-presentation
Case Objectives
Define aortic dissection.
Describe the epidemiology of acute aortic dissection.
State the common and uncommon presentation of acute aor…
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hcup-us.ahrq.gov/reports/statbriefs/sb145.pdf
March 01, 2012 - difficile (ICD-9 code 008.45) 37.6 16.5 39.3 15.1
Septicemia (except in labor) 13.7 12.1 13.9 11.8
Congestive … heart failure 4.0 4.9 3.6 5.0
Complication of device, implant or graft 3.4 4.2 3.2 4.2
Pneumonia