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Showing results for "death".

161. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40831/psn-pdf
     October 05, 2011 - 'Alarm fatigue’ a factor in 2nd death. October 5, 2011 Kowalczyk L. Boston Globe. …   https://psnet.ahrq.gov/issue/alarm-fatigue-factor-2nd-death Reporting on a patient death involving … https://psnet.ahrq.gov/issue/alarm-fatigue-factor-2nd-death https://psnet.ahrq.gov/issue/patient-alarms-often-unheard-unheeded

162. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39347/psn-pdf
     September 30, 2015 - MGH death spurs review of patient monitors. September 30, 2015 Kowalczyk L. Boston Globe. … https://psnet.ahrq.gov/issue/mgh-death-spurs-review-patient-monitors This news account discusses a patient … death after a heart monitor alarm was inadvertently turned off. … https://psnet.ahrq.gov/issue/mgh-death-spurs-review-patient-monitors

163. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36726/psn-pdf
     January 22, 2017 - Eliminating preventable death at Ascension Health. … Eliminating preventable death at Ascension Health. Jt Comm J Qual Patient Saf. 2007;33(3):145-54. … https://psnet.ahrq.gov/issue/eliminating-preventable-death-ascension-health The authors report the results … https://psnet.ahrq.gov/issue/eliminating-preventable-death-ascension-health https://psnet.ahrq.gov//#

164. Maternal deaths at MetroWest hospital prompt state probes. | PSNet
     psnet.ahrq.gov/issue/maternal-deaths-metrowest-hospital-prompt-state-probes
     August 24, 2016 - Maternal death is a sentinel event . … November 21, 2007 MGH death spurs review of patient monitors. … June 8, 2011 'Alarm fatigue’ a factor in 2nd death.

165. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60809/psn-pdf
     August 12, 2020 - Avoiding care during the pandemic could mean life or death. August 12, 2020 Glionna JM. … https://psnet.ahrq.gov/issue/avoiding-care-during-pandemic-could-mean-life-or-death The reluctance of … https://psnet.ahrq.gov/issue/avoiding-care-during-pandemic-could-mean-life-or-death https://psnet.ahrq.gov

166. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50667/psn-pdf
     November 13, 2019 - Proactive prevention of maternal death from maternal hemorrhage. November 13, 2019 Quick Safety. … https://psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage The reduction of … https://psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage http://psnet.ahrq.gov

167. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46550/psn-pdf
     November 15, 2017 - "It's the difference between life and death": the views of professional medical interpreters on their … "It's the difference between life and death": The views of professional medical interpreters on their … https://psnet.ahrq.gov/issue/its-difference-between-life-and-death-views-professional-medical-interpreters … https://psnet.ahrq.gov/issue/its-difference-between-life-and-death-views-professional-medical-interpreters-their-role … https://psnet.ahrq.gov/issue/its-difference-between-life-and-death-views-professional-medical-interpreters-their-role

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41601/psn-pdf
     August 15, 2012 - The short life and lonely death of Sabrina Seelig. August 15, 2012 Hartocollis A. … https://psnet.ahrq.gov/issue/short-life-and-lonely-death-sabrina-seelig This newspaper article reports … on the missteps that contributed to the death of a young woman after she was hospitalized in an incident … https://psnet.ahrq.gov/issue/short-life-and-lonely-death-sabrina-seelig https://psnet.ahrq.gov/issue/

169. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854264/psn-pdf
     October 04, 2023 - Patient death tied to lack of proper escalation process for barcode scanning failures. … https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures … https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures

170. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36078/psn-pdf
     July 03, 2013 - Inquiry into reporter's death finds multiple failures in care. July 3, 2013 Stout D. … https://psnet.ahrq.gov/issue/inquiry-reporters-death-finds-multiple-failures-care This article reports … on the investigation following the death of New York Times reporter David E. … https://psnet.ahrq.gov/issue/inquiry-reporters-death-finds-multiple-failures-care

171. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41821/psn-pdf
     November 07, 2012 - Death of a boy prompts new medical efforts nationwide. November 7, 2012 Dwyer J. New York Times. … https://psnet.ahrq.gov/issue/death-boy-prompts-new-medical-efforts-nationwide Reporting on the death … https://psnet.ahrq.gov/issue/death-boy-prompts-new-medical-efforts-nationwide https://psnet.ahrq.gov/

172. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74119/psn-pdf
     November 24, 2021 - When we're all responsible for a patient's death, no one is. … https://psnet.ahrq.gov/issue/when-were-all-responsible-patients-death-no-one The issue of system versus … https://psnet.ahrq.gov/issue/when-were-all-responsible-patients-death-no-one https://psnet.ahrq.gov/issue

173. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35287/psn-pdf
     June 30, 2009 - Surgical accountability in the 1880s: the death of Susan Nixon. … Surgical accountability in the 1880s: the death of Susan Nixon. … https://psnet.ahrq.gov/issue/surgical-accountability-1880s-death-susan-nixon Using an account of surgical … https://psnet.ahrq.gov/issue/surgical-accountability-1880s-death-susan-nixon https://psnet.ahrq.gov//

174. Ranking hospitals on avoidable death rates derived from retrospective case record review: methodological observations and limitations. | PSNet
     psnet.ahrq.gov/issue/ranking-hospitals-avoidable-death-rates-derived-retrospective-case-record-review
     August 10, 2022 - Commentary Ranking hospitals on avoidable death rates derived from retrospective … Ranking hospitals on avoidable death rates derived from retrospective case record review: methodological … Ranking hospitals on avoidable death rates derived from retrospective case record review: methodological … View More Related Resources Ranking hospitals based on preventable hospital death

175. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37075/psn-pdf
     October 03, 2011 - Outreach and Early Warning Systems (EWS) for the prevention of Intensive Care admission and death of … Outreach and Early Warning Systems (EWS) for the prevention of Intensive Care admission and death of … psnet.ahrq.gov/issue/outreach-and-early-warning-systems-ews-prevention-intensive-care- admission-and-death … psnet.ahrq.gov/issue/outreach-and-early-warning-systems-ews-prevention-intensive-care-admission-and-death … psnet.ahrq.gov/issue/outreach-and-early-warning-systems-ews-prevention-intensive-care-admission-and-death

176. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44025/psn-pdf
     February 22, 2018 - The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best … The Causes of Their Death Appear (Unto Our Shame Perpetual): Why Root Cause Analysis Is Not the Best … https://psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause- analysis-not-best-model … https://psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause-analysis-not-best-model … https://psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause-analysis-not-best-model

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43871/psn-pdf
     March 17, 2015 - FDA begins inquiry after death and illness from saline bags meant for training. … https://psnet.ahrq.gov/issue/fda-begins-inquiry-after-death-and-illness-saline-bags-meant-training This … training purposes was inadvertently distributed and used for actual care and led to patient harm and death … https://psnet.ahrq.gov/issue/fda-begins-inquiry-after-death-and-illness-saline-bags-meant-training

178. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34622/psn-pdf
     March 17, 2011 - National Confidential Enquiry into Patient Outcome and Death. … March 17, 2011 National Confidential Enquiry into Patient Outcome and Death; NCEPOD https://psnet.ahrq.gov … /issue/national-confidential-enquiry-patient-outcome-and-death Launched under the title National Confidential … https://psnet.ahrq.gov/issue/national-confidential-enquiry-patient-outcome-and-death

179. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38336/psn-pdf
     January 14, 2009 - Proceedings of a summit on preventing patient harm and death from IV medication errors. … January 14, 2009 Proceedings of a summit on preventing patient harm and death from i.v. medication errors … https://psnet.ahrq.gov/issue/proceedings-summit-preventing-patient-harm-and-death-iv-medication-errors … https://psnet.ahrq.gov/issue/proceedings-summit-preventing-patient-harm-and-death-iv-medication-errors

180. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43003/psn-pdf
     March 05, 2014 - Learning from every death. March 5, 2014 Huddleston JM, Diedrich DA, Kinsey GC, et al. … Learning from every death. J Patient Saf. 2014;10(1):6-12. doi:10.1097/PTS.0000000000000053. … https://psnet.ahrq.gov/issue/learning-every-death This commentary describes how design and implementation … https://psnet.ahrq.gov/issue/learning-every-death https://psnet.ahrq.gov/issue/saving-lives-studying-deaths-using-standardized-mortality-reviews-improve-inpatient-safety