AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (12)

•Identification Errors (1)

•Discontinuities, Gaps, and Hand-Off Problems (19)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (23)

•Medical Complications (21)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (6)

•Transfusion Complications (1)

•Psychological and Social Complications (2)

Origin/Sponsor

•Australia and New Zealand (2)

•North America (66)

Resource Types

•Book/Report (1)

•Clinical Guideline (1)

•Journal Article (70)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (4)

Error Types

•Epidemiology of Errors and Adverse Events (28)

•Active Errors (24)

•Latent Errors (7)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (11)

•Legal and Policy Approaches (4)

•Error Reporting and Analysis (17)

•Communication Improvement (17)

•Human Factors Engineering (5)

•Teamwork (3)

•Specialization of Care (19)

•Logistical Approaches (9)

•Culture of Safety (6)

•Technologic Approaches (10)

•Education and Training (12)

Clinical Areas
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Cardiology

Target Audience

•Health Care Providers (63)

•Health Care Executives and Administrators (59)

•Non-Health Care Professionals (17)

•Patients (3)

Setting of Care

•Hospitals (62)

•Residential Facilities (1)

•Ambulatory Care (8)

•Patient Transport (1)

1 - 20 of 78

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STUDY

Contemporary evidence about hospital strategies for reducing 30-day readmissions: a national study.

Bradley EH, Curry L, Horwitz LI, et al. J Am Coll Cardiol. 2012;60:607-614.

BOOK/REPORT

Hospital Performance Report.

Trenton, NJ: New Jersey Department of Health and Senior Services; March 2012.

STUDY

Impact of an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality.

Al-Qahtani S, Al-Dorzi HM, Tamim HM, et al. Crit Care Med. 2013;41:506-517.

STUDY

SBAR: electronic handoff tool for noncomplicated procedural patients.

Wentworth L, Diggins J, Bartel D, Johnson M, Hale J, Gaines K. J Nurs Care Qual. 2012;27:125-131.

STUDY

Physician implicit review to identify preventable errors during in-hospital cardiac arrest.

Jain R, Kuhn L, Repaskey W, et al. Arch Intern Med. 2011;171:89-90.

STUDY

Perceptions of hospital safety climate and incidence of readmission.

Hansen LO, Williams MV, Singer SJ. Health Serv Res. 2011;46:596-616.

STUDY

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries.

Press MJ, Silber JH, Rosen AK, et al. J Gen Intern Med. 2011;26:405-411.

NEWSPAPER/MAGAZINE ARTICLE

Saving lives: hospitals have signed on to a six-part plan to avoid a multitude of unnecessary deaths.

Comarow A. US News & World Report. July 18, 2005;139:74,76,79.

STUDY

Weekend versus weekday admission and mortality from myocardial infarction.

Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE, for the Myocardial Infarction Data Acquisition System (MIDAS 10) Study Group. N Engl J Med. 2007;356:1099-1109.

STUDY

Nurses' perceptions of subspecialization in pediatric cardiac intensive care unit: quality and patient safety implications.

Kane JM, Preze E. J Nurs Care Qual. 2009;24:354-361.

STUDY

Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.

Davidenko JM, Snyder LS. J Electrocardiol. 2007;40:450-457.

COMMENTARY

Intrahospital transport to the radiology department: risk for adverse events, nursing surveillance, utilization of a MET and practice implications.

Ott LK, Hoffman LA, Hravnak M. J Radiol Nurs. 2011;30:49-52.

STUDY

Nurse decision making in the prearrest period.

Gazarian PK, Henneman EA, Chandler GE. Clin Nurs Res. 2010;19:21-37.

STUDY

classic

Use of medical emergency team responses to reduce hospital cardiopulmonary arrests.

DeVita MA, Braithwaite RS, Mahidhara R, et al. Qual Saf Health Care. 2004;13:251-254.

STUDY

classic

Delayed time to defibrillation after in-hospital cardiac arrest.

Chan PS, Krumholz HM, Nichol G, Nallamothu BK, and American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. N Engl J Med. 2008;358:9-17.

STUDY

Reporting and classification of patient safety events in a cardiothoracic intensive care unit and cardiothoracic postoperative care unit.

Nast PA, Avidan M, Harris CB, et al. J Thorac Cardiovasc Surg. 2005;130:1137.

COMMENTARY

Crushing Chest Pain: A Missed Opportunity.

Graber M. AHRQ WebM&M [serial online]. January 2004.

COMMENTARY

Are Two Insulin Pumps Better Than One?

Cook CB. AHRQ WebM&M [serial online]. January 2009.

STUDY

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.

Alexander KP, Chen AY, Roe MT, et al; CRUSADE Investigators. JAMA. 2005;294:3108-3116.

STUDY

Four years' experience with a hospitalist-led medical emergency team: an interrupted time series.

Rothberg MB, Belforti R, Fitzgerald J, Friderici J, Keyes M. J Hosp Med. 2012;7:98-103.

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