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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 26 Results
WebM&M Case November 30, 2023

A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac resynchronization and defibrillator device (CRT-D) implantation. The procedure was successful and he was discharged the next day with instructions to resume his prior medications, including empagliflozin. He presented to the emergency department the following day where he was diagnosed with euglycemic diabetic ketoacidosis (eDKA) and he was transferred to the intensive care unit (ICU) for insulin infusion.

Doorey AJ, Turi ZG, Lazzara EH, et al. Catheter Cardiovasc Interv. 2022;99:1953-1962.
Closed loop communication (CLC) ensures a clear transfer of information by having the recipient repeat the order for verification.  In this study, procedures in the cardiac catheterization lab were observed to assess the frequency and accuracy of CLC. Despite three interventions over five years (education, on-going feedback, accountability), CLC remained suboptimal, with both incomplete orders given and incomplete responses.
WebM&M Case May 16, 2022

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.

Kwok CS, Bennett S, Azam Z, et al. Crit Pathw Cardiol. 2021;20:155-162.
Misdiagnosis of cardiovascular conditions can lead to serious patient harm. This systematic review found that misdiagnosis of acute myocardial infarction (AMI) occurs in approximately 1-2% of cases, and AMI is commonly diagnosed as other heart conditions, musculoskeletal pain, or gastrointestinal disease. The authors suggest that there are opportunities to reduce cases of missed AMI with better education about atypical symptoms and improved training of electrocardiogram interpretation.
Jagneaux T, Caffery TS, Musso MW, et al. J Patient Saf. 2021;17:425-429.
Emergency and internal medicine residents attended a course on central venous access that included lectures, videos, and simulation using a task trainer. Comparison of pre- and post-training evaluation demonstrated significant improvement in knowledge, confidence, and procedural skills.
Davis DP, Aguilar SA, Lawrence B, et al. Jt Comm J Qual Patient Saf. 2018;44:413-420.
This analysis of a training program in hospital-based identification of clinical deterioration and resuscitation found that most cardiopulmonary arrest events can be reliably classified by the study team's novel taxonomy into 1 of 12 clinical entities. The authors suggest that using this taxonomy can better elucidate the effects of interventions to improve outcomes of cardiopulmonary arrest in inpatient settings.
Perspective on Safety June 1, 2017
This piece explores the weekend effect in cardiology and recommends allowing invasive management for patients with non ST-elevation myocardial infarction to improve outcomes in this group.
This piece explores the weekend effect in cardiology and recommends allowing invasive management for patients with non ST-elevation myocardial infarction to improve outcomes in this group.
Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London. We spoke with him about the weekend effect in health care—the observation that patients admitted to the hospital over the weekend often have worse outcomes than those admitted during the week.
Jordan KP, Timmis A, Croft P, et al. BMJ. 2017;357:j1194.
Missed and delayed diagnoses are an increasingly recognized patient safety problem. A common undiagnosed symptom in outpatient medicine is chest pain. This retrospective cohort study compared outcomes for three groups of patients with chest pain: those whose pain remained undiagnosed after 6 months versus those diagnosed with either coronary artery disease or a verified noncardiac cause of chest pain. Only a minority of the undiagnosed patients underwent diagnostic testing for coronary artery disease. The highest risk of myocardial infarction was in patients with diagnosed coronary artery disease, but undiagnosed patients were more likely to have a myocardial infarction than those with verified noncardiac disease. The authors conclude that patients without a timely diagnosis merit further evaluation to reduce the risk of cardiovascular events.
Eindhoven DC, Borleffs JW, Dietz MF, et al. BMJ Open. 2017;7:e014360.
Although adverse events among hospitalized patients are common, less is known about the safety of acute cardiac care. In this retrospective study, researchers described the development and validation of a tool to assess the safety of patients treated for acute myocardial infarction.
Barbeito A, Bonifacio AS, Holtschneider M, et al. Simul Healthc. 2015;10:154-62.
Realistic in situ simulations of cardiac arrest scenarios, conducted in actual clinical settings without advance notification of participants, identified several latent errors in a hospital's emergency response system. Dr. David Gaba, a pioneer in simulation in health care, was interviewed for AHRQ WebM&M in 2013.
Cahill TJ, Clarke SC, Simpson IA, et al. Heart. 2015;101:91-3.
Drawing from the success of the WHO surgical safety checklist initiative, this commentary describes the development of a checklist created to improve the reliability of core invasive cardiac procedures such as diagnostic angiography. The authors discuss the role of nurses in introducing the checklist and the use of team briefings to reduce the risk of communication errors. An example of the checklist tested is included.
Dandoy CE, Davies SM, Flesch L, et al. Pediatrics. 2014;134:e1686-e1694.
Improving alarm systems to mitigate the risks of alarm fatigue was added as a National Patient Safety Goal in the 2014 update. This study introduced a multifaceted cardiac monitor care process on a pediatric bone marrow transplant unit. The program included standardized steps for ordering and reassessing cardiac monitor parameters. In addition, physicians and nurses used a log to document the need for ongoing cardiac monitoring and created reliable systems for discontinuation of monitoring when it was no longer needed. Patients and families were actively engaged in these activities, helping sustain the program. As compliance with the process improved from 38% to 95%, the number of alarms per patient-day plummeted from 180 to 40. The hope is that reducing unnecessary alerts will address clinician desensitization to clinically important alarms.
Braham DL, Richardson AL, Malik IS. Clin Med. 2014;14:468-474.
The World Health Organization's surgical safety checklist has been widely implemented in surgical practice to prevent errors. This study provides an in-depth description of how the checklist was modified and applied in cardiac catheterization procedures, demonstrating the potential to adapt this safety intervention in other procedural areas.
Tsai TT, Maddox TM, Roe MT, et al. JAMA. 2009;302:2458-64.
Patients hospitalized for cardiac problems are vulnerable to experiencing medication errors, as they are commonly prescribed high-risk medications such as anticoagulants and antiplatelet agents. This analysis of more than 22,000 hemodialysis patients undergoing percutaneous coronary interventions (PCI) (for example, angioplasty) found that 22.3% were administered either enoxaparin or eptifibatide, medications that are contraindicated in dialysis patients due to excessive bleeding risk. This risk was borne out in the study, as patients who received the contraindicated medications did in fact have more major bleeding episodes. The high prevalence of serious medication errors in this study argues for education and use of forcing functions to prevent misuse of these medications.